Title: Network analysis of stress and stigma symptoms and their associations with quality of
life among Chinese female infertility patients
Version: 1 Date: 11 Aug 2024
Reviewer:  Marcelo De França de França Moreira
Reviewer's report:
Thank you for the opportunity to review this manuscript. The authors explore the interplay
between stress, stigma, and quality of life in female infertility patients using network analysis.
This topic is timely and significant, especially given the psychological complexities surrounding
infertility. However, my primary concerns revolve around the statistical analysis and handling
of potential confounds, which are crucial for substantiating the associations observed in the
study. The discussion also requires adjustments to more accurately reflect the limitations and
implications of the findings, as detailed below.
Abstract
Please describe the study design in the method section of the abstract.
Introduction
Because the quality of life includes mental health, it may be more appropriate to make a slight
change in the phase:
"It not only harms the mental health of infertility patients but also affects  [other components of]
their quality of life, causing them to experience adverse social consequences such as domestic
violence, marriage breakdown, or even delay in receiving treatment."
The second paragraph of page two must be improved:
It is unclear what "at the symptom level" means in the statement: "However, few studies have
focused on the relationship between these two variables at the symptom level." Consider revising
this to more directly address the complexity of these variables, such as "few studies consider the
multidimensional nature of these variables."
The authors should reorganize the ideas they tried to convey to improve comprehension. It
may be more comprehensive to reformulate, like, "Individuals may exhibit a unique mosaic of
symptoms related to stress and stigma, each contributing variably, delineating distinct subgroups
that are crucial for the tailored management of infertile women." Improve management seems
a more appropriate consequence of the present study than "make the measures more specific
and targeted".
Then, point out that the traditional approach employed to study the relationship between these
variables fails to capture this complexity. The usual method of summing symptoms to represent
stress and stigma weighs all symptoms equally and ignores the significant differences between
specific symptoms and relationships among symptoms.
While certain personality traits may predispose individuals to higher perceived stress and
susceptibility to stigma, it is important to clarify that stress and stigma themselves are not traits.
This distinction should be clearly stated to avoid conceptual confusion.
The phrase 'Exploring the relationship between the symptom dimensions will make the measures
more specific and targeted' could be improved. A later statement you use, 'could increase
the specificity and targeting of interventions,' more accurately reflects the potential benefits.
Consider emphasizing this improved management outcome earlier in your manuscript.
Refining the transitions between some of the statements in the third paragraph may be beneficial.
Currently, the flow from one idea to the next feels somewhat abrupt.
There are several instances of word repetition within the same phrases throughout the
manuscript; for example, the word 'specific' is used multiple times close together in phrases.
Additionally, terms like 'stress and stigma' are also repeated closely in contexts that might benefit
from varied language.
Method
Including a geographic map in Figure 1 detailing the location and topography of the study sample
may not provide essential information relevant to the understanding or outcomes of the study.
Consider removing this figure.
The inclusion criterion 'agreed and signed an informed consent form' should be considered a
standard ethical requirement rather than an inclusion criterion.
The listing of 'voluntary withdrawal or incomplete information' as exclusion criteria is incorrect.
These issues should be addressed as part of data management processes rather than criteria for
excluding participants at the outset. It is crucial to relocate this point to a section discussing how
data from withdrawn participants or incomplete datasets are handled after enrollment.
The detail 'A total of 428 female infertility patients completed the survey...for an effective
response rate of 99.77%' is mistakenly placed in the Methods section. This information should
be relocated to the Results section, as it pertains to study outcomes rather than procedural details.
The title 'Assessment' inaccurately suggests a broader evaluation and should be changed
to 'Measures' or 'Instruments' to reflect the content focused on the data collection tools.
Additionally, the 'Procedure' section must precede 'Measures' to align with standard research
formatting.
The 'Procedure' section lacks specifics on data collection, such as whether assessments were
conducted via paper or electronic forms. Please clarify this to provide a complete overview of
the data collection process.
Statistical analysis
The lack of comprehensive details on the statistical methods used for calculating predictability,
centrality indices, and network stability represents a critical oversight that must be addressed,
along with other essential elements:
Specify the version of R and the packages used to ensure reproducibility.
Briefly explain the choice of graphical Gaussian models (GGM) and polychoric correlations to
justify the analytical approach.
Include a concise description of how predictability is calculated and its relevance to interpreting
the results.
Thresholds used for LASSO and EBIC models should be provided
Specific statistical methods used to calculate predictability and centrality indices should be
provided.
Methods and criteria used for testing the stability of the network should also be included.
Report how statistical significance thresholds were defined, such as p-values or confidence
intervals.
Detailed Component Analysis: If principal component analysis (PCA) or similar techniques
were used:
Clearly state the number of components retained and the criteria for this decision.
Provide details on component loadings to aid in the interpretation of what each component
represents.
Describe any rotation methods used in PCA to clarify how the components were oriented.
Detail the process used for constructing the network after PCA. Include information on whether
raw data or PCA components were used to build the network.
Justify why PCA was chosen and how it aligns with the objectives of the network analysis. If
PCA was used, explain how it contributed to understanding the relationships between symptoms.
To accurately interpret the study's results, it is essential to critically assess potential confounds.
The study measured variables like age, education level, and duration of infertility, yet it is
not clear why these were not adjusted for in the analysis. Furthermore, important potential
confounders such as menstrual pain, mental health status and hormonal imbalances, which were
not measured, should also be acknowledged. Ideally, the analysis should be rerun incorporating
controls for the measured confounders.
Results
In the results section, consider removing skewness and kurtosis from the tables, as their inclusion
may not add significant value. Instead, simply note that these measures were assessed to guide
the choice of central tendency—mean and SD or median and IQR—which could be presented
for clarity.
The results currently lack a clear explanation of the edge weights. Including this information is
essential for understanding the implications of the network relationships observed.
The presentation of network findings needs to be more detailed. It is important to articulate the
significance of the observed patterns to enhance the clarity and impact of your results.
Discussion
The discussion section contains several areas that need refinement to enhance clarity, coherence,
and the substantiation of claims.
Replace ‘explicit’ (first paragraph) with a more precise term like 'clear' or 'detailed' to accurately
reflect the nature of the structure provided by the network analysis.
The use of 'communities' in “Self-devaluation”, “social concern”, and “relationship concern”
were the main symptoms bridging the FPI and ISS communities." is unclear. Suggest defining
'communities' or replacing it with a more appropriate term like 'groups' or 'clusters' unless it is
justified earlier in the text.
The phrase "Intervention focused on these symptoms could reduce cooccurring stress and stigma
among female infertility patients." should be integrated into a paragraph discussing potential
interventions, rather than being isolated. Suggest restructuring sentences to connect this idea
smoothly with surrounding text.
Statements like "Undoubtedly, infertility is a major event affecting family relationships" and
other similar claims require citations to support these assertions. Encourage authors to provide
references for all factual statements and interpretations.
Address disjointed transitions, particularly "Sexual dissatisfaction may also further worsen
couples’ relationships." Suggest creating smoother transitions between ideas to improve
readability and logical progression.
For the phrase “Social public opinion has also caused great pressure on female infertility
patients.” suggest rephrasing or better integrating this sentence to align with the paragraph's
overall focus.
The last quoted paragraph has multiple issues including repeated and disconnected phrases.
Suggest consolidating the findings and recommendations into a cohesive narrative. This includes
aligning the discussion about 'central symptoms' and their implications consistently across the
text.
In the discussion, it's crucial to address potential confounders like menstrual pain and mental
health issues that could influence the observed associations. This discussion could also explore
how these factors might provide alternative explanations for the observed associations, ensuring
a comprehensive understanding of the research context and its applicational boundaries.
Limitations
The authors do not point out important study limitations, critical for interpreting the study’s
results accurately, should be explicitly stated in the manuscript to ensure a comprehensive
understanding of the research context and its applicational boundaries:
Recognizing potential confounds that may impact the findings is crucial, given the study's broad
inclusion and minimal exclusion criteria. Explicitly discuss the omission of these variables in
the statistical analysis and mention non-measured confounders as part of the limitations.
Moreover, focusing exclusively on infertile women restricts the ability to control for confounds
that may uniquely affect this group compared to the general population. This limitation hinders
the assessment of how relationships might differ between infertile and fertile women. This
restriction impacts the generalizability of the findings and could obscure the specific stressors
or stigma manifestations unique to infertility.
Limitations inherent to the study’s cross-sectional design; it has limited potential to determine
the directionality or extent of the interactions between stress, stigma, and infertility.