Owing to the environmental pollution, fertility age delay, life pressure and so on, the number of infertile couples is increasing1. There is increasing evidence shows that infertility-related stress negatively predicts quality of life2. However, we are still unaware of the underlying psychological mechanism of how and why infertility-related stress affected quality of life.

Negative emotions may link the relationship between infertility-related stress and quality. In China, the traditional Chinese culture believes that “there are three types of unfilial piety, having no child is the greatest”, and fertility is regarded as an unshakable duty in life. Therefore, infertile individuals often bear great infertility-related stress, many studies have shown that infertile couples tend to experience a variety of negative emotions, including anxiety, depression, fear, avoidance, and guilt, all of which can lead to overall life dissatisfaction2,3. In addition, Geng et al. found that negative emotions were negatively linked to quality of life4. Thus, we regarded negative emotions (depression and anxiety) as a mediator between infertility-related stress and quality of life (H1).

According to diathesis-stress theory and organism–environment interaction model, individuals with unique attributions and characters will respond to similar situations differently, the dynamics of individual and contextual interactions will contribute to the individual’s psychological and social adaptation5,6. This means that individuals with different intrapersonal attributes may respond differently even in the same situation5. So, it is necessary to investigate which intrapersonal attributes will moderate the relationship between infertility-related stress and quality of life. In present study, we supposed that Dark Triad (i.e., Machiavellianism, narcissism and psychopathy)7, is one of such intrapersonal attribute variables that will play a moderating role. Dark Triad, which was at the opposite side of “Big Five personality”, and it contained three dark personality traits: Machiavellianism, narcissism, and psychopathy8. Machiavellianism could be considered as an “amplifier” to enlarge individual differences9. Individuals with high Machiavellianism were found to be more likely to respond to contextual cues10, so Machiavellianism may intensify the negative effect of infertility-related stress on quality of life. Besides, high level of psychopathy can predict less depressive and anxiety symptoms11, and may be considered as an “eliminator” of negative emotions12,13. Thus, it is reasonable for us to hypothesize that Dark Triad will moderate the relations among infertility-related stress, negative emotions, and quality of life (H2).

Gender cannot be ignored when discussing the relations among infertility-related stress, negative emotions, and quality of life. In general, Males scored lower on negative emotions but higher on quality of life than females14,15,16. Therefore, another goal of this study was to verify the moderating effect of gender in the process of infertility-related stress affects negative emotions and quality of life (H3).

The present study aims to examine whether negative emotions mediated the relation between infertility-related stress and quality of life, and whether the Dark Triad personality and gender could moderate the negative effect of infertility-related stress on negative emotions and quality of life. The hypothesized model is shown in Fig. 1.

Fig. 1
figure 1

The hypothesized model.

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Methods

Study population

Infertile outpatients who were undergoing treatment were recruited from the reproductive medicine center of the third affiliated hospital of Zhengzhou university, Henan Province, China. Inclusion criteria were Infertile outpatients couples undergoing assisted reproductive technique (ART) treatments and age (male older than 22 years and female older than 20 years were allowed to marry). We excluded participants with an inadequate understanding of Mandarin and/or those with a history of psychiatric disorders, defined as having received a psychiatric diagnosis and/or a pharmacological treatment for a psychiatric disorder during the course of their life. A total of 127 outpatients met the inclusion criteria for the study, while 22 (17.32%) declined. Non-participation was mainly due to time constraints and rarely to male reluctance. Finally, 105 infertile outpatients (35 male and 70 female) remained. Using G*Power 3.1.9.7. to calculate the required sample size, it is assumed that R2 = 0.13, 1 − β = 0.8, and α = 0.05. At least 68 participants are required to calculate the multiple regression model. As a result, the sample is valuable.

The sample age ranging from 20 to 49 years old with a mean age of 31.99 (SD = 5.17). The demographic characteristics could be found in Table 1.

Table 1 Participant fertility and demographic characteristics (N = 105).
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Procedure

First, we contacted with the leaders of the investigated hospital in advance and obtained the permission and support of the survey. After obtaining the informed consent of the infertile outpatients, we delivered questionnaire to them. The purpose and significance of the survey were explained to the infertile outpatients. The study was carried out in accordance with the approved guidelines and regulations before data collection.

Measurements

Infertility-related stress

Infertility-related stress was measured using the 46-item Fertility Problem Inventory2. This scale consists of 5 dimensions: Social concern, sexual concern, relationship concern, need for parenthood, rejection of childfree lifestyle. Participants answered on a 6-point Likert scale, ranging from 1 (totally disagree) to 7 (totally agree). The higher score represented higher level of infertility-related stress. Cronbach’s α was 0.89.

Quality of life

Quality of life was measured using the 34-item Fertility Quality of Life (FertiQoL) scale17. This scale consists of 2 subscales. Core subscale consists of emotional, mind–body, relational, and social dimensions. Treatment subscale consists of Environment and Treatment tolerability dimensions. Participants answered on a 5-point Likert scale, ranging from 0 to 4 and the score can be converted into 0–100. The higher score represented higher level of quality of life. Cronbach’s α was 0.93.

Negative emotions

Negative emotions were measured using the 14-item Hospital Anxiety and Depression Scale (HADS)18. This scale consists of depression subscale, anxiety subscale. Participants answered on a 4-point Likert scale. Scores ranging from 0 to 7 (No cases), 8–10 (Doubtful cases), 11–21 (Cases). In the present study, we calculated the sum score of depression and anxiety as the score of negative emotions, the higher score represented higher level of negative emotions. Cronbach’s α was 0.84.

Dark triad personality

Dark triad personality was measured using the 12-item Chinese version of Dirty Dozen (DD)15. This scale consists of three dimensions. Machiavellianism, narcissism, psychopathy. Participants answered on a 7-point Likert scale, ranging from 1 (totally disagree) to 7 (totally agree). The higher score represented higher level of dark triad personality. Cronbach’s α was 0.89.

Statistical analyses

SPSS 28 software was used to perform data analyses in this study. Gender differences for all variables were analyzed by independent-samples T test. The correlations of all variables were analyzed by Pearson correlation analysis. The mediation and moderated mediation model were tested using the PROCESS macro for SPSS19.

Ethical approval

The study was approved in June 2022 by the Ethical Committee of Zhengzhou University (Reference No.: 196) and carried out in accordance with the approved guidelines and regulations. All participantss confirmed their compliance through written informed consent.

Results

Gender differences

Apart from males scored marginally higher on Machiavellianism, narcissism and Dark triad than females, there was no significant difference between males and females in other variables. The results could be found in Table 2.

Table 2 Gender differences of the variables.
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Descriptive data and correlations

Results showed that infertility-related stress was negatively associated with quality of life, and positively associated with negative emotions. Dark Triad was negatively associated with quality of life, especially for narcissism, and positively associated with infertility-related stress, especially for psychopathy and narcissism. The results of correlation analyses were shown in Table 3.

Table 3 Means, standard deviations, and correlations of the variables.
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Mediation analysis

Model 4 in PROCESS was used to test the mediation effect19. We used maximum likelihood estimation and the bias-corrected bootstrap 95% confidence interval base on 5000 bootstrapping. Results showed that infertility-related stress could directly predict quality of life, and indirectly predict quality of life via negative emotions (Fig. 2). The direct effect of infertility-related stress on quality of life was − 0.52, 95% CI [− 0.66, − 0.40], with the indirect effect being − 0.18, 95% CI [− 0.28, − 0.09].

Fig. 2
figure 2

Negative emotions as a mediator between fertility-related stress and quality of life. Standardized regression weights are reported. All significant pathways are p < 0.001.

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Moderated mediation analysis

Model 59 in PROCESS was used to test the moderated mediation effect19. Unfortunately, evidence of moderation by Dark Triad was absent. However, results showed that gender can moderate the associations between infertility-related stress and negative emotions, with the association of infertility-related stress and negative emotions was stronger for males (β = 0.21, t = 5.23, p < 0.001) than for females (β = 0.06, t = 2.89, p < 0.01) (Fig. 3).

Fig. 3
figure 3

Negative emotions as a function of Infertility-related stress and gender. IS = Infertility-related stress.

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Discussion

To the best of our knowledge, this is the first study that simultaneously examined various potentially psychological variables that are related to quality of life among infertile outpatients, which extends our knowledge of the exact relations among infertility-related stress, negative emotions, Dark Triad and quality of life.

First of all, the t test results showed that males reported marginally higher levels of Machiavellianism and narcissism than females, suggesting that Machiavellianism and narcissism may be tapping into something characteristically male, and males are more suspicious of others and narcissistic7,20. Besides, although it was not statistically significant that males showed a tendence of worse emotional patterns than female, this suggested that in Chinese families, males beared the goal of reproduction and the greater pressure of infertility.

Then the correlation analyses demonstrated that (1) infertility-related stress had an adverse effect on quality of life among infertile outpatients, which was in accordance with previous studies2,21. Infertility is not a fatal disease but it is always related to guilt and shame, and is usually considered as an unfilial behavior, especially in the Chinese culture context. In China, infertile couples believe that their marriage and family life fail to meet their expectations, and they feel that their quality of life is low for the reason of having no kids. Infertility and the treatment failure experiences will cause great distress to patients, and threaten the quality of life of them22; (2) Dark Triad was negatively associated with quality of life among infertile outpatients, which was consistent with previous studies. For example, research revealed that pathological narcissism will lead to interpersonal relationship problems23, which may lower quality of life. Another previous study also revealed that individuals higher in Machiavellianism reported higher sexual fear and anxiety24, meaning low sexual quality of life. Besides, we knew that Machiavellianism and psychopathy were known as hostile interpersonal style and low self-control25. Hostile interpersonal style would harm interpersonal relationship, which could reduce the probability of getting social support—a significant predictor of quality of life26. Thus, it is reasonable to infer that the Dark Triad negatively predicts quality of life among infertile outpatients; (3) It is noteworthy that Dark Triad was positively associated with infertility-related stress. These results indicated that individual high in Dark Triad were inclined to report higher level of stress, which are consistent with previous researches7,15. For example, Birkás found that Dark Triad was related to perceived stress27 and narcissism predicted greater stress when stress-management through music was not frequent28.

As for the mediating hypothesis, as expected, negative emotions were found to play a mediating role in the relationship between infertility-related stress and quality of life, which was consistent with previous studies. First, a plenty of studies had demonstrated that infertility-related stress would lead to negative emotions29. Second, negative emotions could produce adverse effect on quality of life30. On the one hand, negative emotions could affect individuals’ well-being regarded as one important indicator of quality of life31. On the other hand, negative emotions could also have a negative impact on the infertility treatment effect32, affecting the quality of life of patients.

Considering Machiavellianism was considered as an “amplifier” of individual differences9, and high level of psychopathy, to some extent, can predict less depressive and anxiety symptoms4,10,11,13, we wanted to find out whether Dark Triad could moderate the link among infertility-related stress, negative emotions and quality of life. However, in the current study, we did not find the moderating effect. Individuals with or without Dark Triad would be affected equally by infertility-related stress. This interesting finding could be explained by the unique fertility culture in Chinese context. In China, “having no child is the greatest unfilial piety” was grounded in people’s minds. Couples who did not have children would feel the intangible stress from their parents, friends, relatives and society. Thus, individuals with or without Dark Triad would suffer from the same level of infertility-related stress which further affected emotions and quality of life for no one could be protected from the influence of fertility culture.

Besides, the moderated mediation analysis indicated that gender can moderate the associations between infertility-related stress and negative emotions, with the association of infertility-related stress and negative emotions was stronger for males than for females. These results mean that the relations between infertility-related stress and negative emotions are more substantial for males, and males actually suffer more emotionally than females when experience infertility in their reproductive lives.

From the findings, we could infer that it was very important to take some measures to reduce the infertile outpatients’ stress and the subsequent negative emotions to improve their quality of life. First, it was well acknowledged that infertile outpatients were more likely to bear economic burden for the expensive treatment fees which may intensify their stress and the long treatment duration, and failure experiences will also contribute to their stress. Family members and friends of infertile outpatients should care about them and offer emotional support as well as economic support if necessary, which would be effective ways to reduce infertile outpatients’ stress and negative emotions. Second, cognitive behavioral therapy was also an effective means to reduce stress and negative emotions for positive cognition was beneficial to mental health but negative cognition was harmful to it33. Thus, transferring negative cognition into positive cognition could help reduce the stress and negative emotions level. Cognitive behavioral therapy could change the negative thoughts that lead to poor mood states and was considered as an important treatment for mental health disorders34,35. Therefore, the hospitals need to offer not only physical treatment but also psychological intervention for good psychological state could produce positive effects on patients’ quality of life and treatment effect.

There are some limitations in this study. First, our results are not representative of the entire population of infertile outpatients. Second, participants were small and contained a disproportionately large number of females. Although we controlled for gender and age in the mediation and moderated mediation analyses, future researchers should attempt to validate these models in a gender balance and larger sample to gain a more reliable result. Third, this study is a cross-sectional survey, and we are unable to make causal inferences. Therefore, further experimental and longitudinal research should be conducted to validate the findings.

Conclusion

Infertility-related stress, negative emotions, and Dark Triad were all predictors of quality of life. Negative emotions partially mediated the relationship between infertility-related stress and quality of life. Gender, rather than Dark Triad, can moderate the associations between infertility-related stress and negative emotions, suggesting that males actually suffer more emotionally than females when experience infertility in their reproductive lives.