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Self-Esteem and Quality of Life Among Women Undergoing IVF-ET: Mediating Role of Coping Strategies
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Received: ,
Accepted: ,
How to cite this article: Tomy T, Vinod Kumar S. Self-Esteem and Quality of Life Among Women Undergoing IVF-ET: Mediating Role of Coping Strategies. Fertil Sci Res. 2026;13:7. doi: 10.25259/FSR_65_2025
Abstract
Objectives:
The study aims to understand how coping strategies mediate the relationship between self-esteem and the Fertility Quality of Life (FertiQoL) in women preparing for in vitro fertilisation (IVF)-embryo transfer (ET).
Material and Methods:
A cross-sectional study was conducted among 346 women preparing for IVF in Kerala, India. Data were collected using a personal data schedule, the FertiQoL questionnaire, the Rosenberg self-esteem scale, and the Copenhagen Multi-Centre Psychosocial Infertility (COMPI) coping strategy scale. Mediation analysis was performed using the PROCESS macro for SPSS (Model 4).
Results:
The result shows that the total effect of self-esteem on FertiQoL was significant (b = 2.2454, SE = 0.1363, t (346) = 16.4782, p <0.001, 95% CI [1.9774, 2.5135], β = 0.6596). The direct effect of self-esteem on FertiQoL also remained significant (b = 1.6343, SE = 0.1487, t (346) = 10.9940, p <0.001, 95% confidence interval (CI) [1.3419, 1.9267], β = 0.4803). This suggests that self-esteem continues to uniquely contribute to the FertiQoL, independent of its effect on coping strategies. The indirect effect of self-esteem on FertiQoL through coping strategies was statistically significant (b = 0.6111, Bootstrap SE = 0.1041, 95% bias-corrected CI [0.4147, 0.8285] β = 0.1796).
Conclusion:
These findings suggest that coping strategies serve as a partial mediator in the relationship between self-esteem and FertiQoL for women undergoing IVF. Consequently, interventions focused on enhancing self-esteem and coping strategies may improve the overall QoL for women in IVF treatment.
Keywords
Coping strategies
Fertility quality of life
Self-esteem
Women undergoing IVF-EF
INTRODUCTION
The process of seeking conception through in vitro fertilisation (IVF) and other assisted reproductive technology (ART) procedures presents a unique and profound life crisis, marked by chronic stress, uncertainty, and emotional turmoil. Infertility extends far beyond a medical diagnosis that leads to psychological distress. This experience is often characterised by significant psychological burdens, including relationship strain, financial stress, and social isolation. In most societies, reproduction and its burden are centred around women, and they are more blamed for childlessness, irrespective of medical reasons, which leads to the feeling of isolation, being gossiped about or insulted for infertility, and the perception of social exclusion.[1]
The social pressure coupled with the strong internal need for a child along with the treatment experience leads to significant anxiety and depression among couples, especially among women, which can be particularly damaging to their psychological well-being.[2,3] This deterioration in emotional status is directly correlated with a gradual and significant decrease in quality of life as the number of IVF cycles increases.[4] This trend indicates that infertility is not merely a single, acute event but rather a protracted crisis requiring durable, long-term psychological resources and adaptive coping mechanisms for successful adjustment.
Self-esteem is regarded as an internal resource that helps to maintain mental health and quality of life. It is defined as an individual’s perception of their abilities, skills, and intrinsic worth. It encompasses the degree to which one values oneself, reflecting confidence, self-worth, and self-acceptance.[5] In the infertility population, women are often reported to exhibit lower levels of self-esteem than their male partners.[6] Expectations and blame due to childlessness affect their self-esteem, which in turn leads to deterioration of their quality of life.[7]
Whenever a person encounters a distressing circumstance, they employ cognitive and physical resources to manage internal or external demands that are perceived as stressful. This coping process starts with primary appraisal, which involves determining whether an event is threatening, challenging, or benign, while secondary appraisal assesses the availability and efficacy of resources to manage the situation. These appraisals dictate the selection of coping strategies, which are generally categorised as reactive or proactive. Reactive coping follows a stressor and aims to mitigate existing damage or distress. Proactive coping, conversely, involves identifying and preparing for future stressors, a practice that fosters stability but can occasionally lead to rigidity in rapidly changing environments.[8] Coping strategies adopted during IVF are crucial self- regulatory processes. They are typically categorised into adaptive (approach-oriented) and maladaptive (avoidance- oriented) types. Adaptive strategies promote emotional stability and clarity, whereas maladaptive strategies, while potentially offering momentary relief, ultimately increase distress and disconnection.
Individuals with higher self-esteem tend to exhibit a greater predisposition to engage in problem-focused and task-oriented coping. High self-esteem is consistently associated with positive emotional coping strategies, including self-love, self-acceptance, cognitive positive reinterpretation, and psychological growth.[9,10] These mechanisms enhance the individual’s internal capacity to manage adversity, facilitating the selection of constructive and adaptive strategies over passive or destructive ones. Conversely, low self-esteem is frequently linked to maladaptive responses like self-blame and mental rumination.[11]
Studies explicitly mapping the mediating effect of coping on the relation between self-esteem and Quality of Life (QoL) among women undergoing IVF are limited. The major objectives of the study are to examine (a) the correlation between self-esteem coping strategies and QoL among women undergoing IVF-embryo transfer (ET) treatment; and (b) the mediating role of the coping strategies on the relation between self-esteem and QoL among women undergoing IVF-ET treatment.
MATERIAL AND METHODS
Design and participants
This exploratory study adopted a correlational design to study QoL among women undergoing IVF in Kerala. A stratified random sampling method was used to recruit women from assisted reproductive centres across different regions from September 2023 to January 2025. The sample size was calculated using the G Power statistics. Keeping the following parameters for linear regression analysis, slope H1at 0.15, alpha level of significance at 0.05, and a power of 0.8, the sample size was estimated to be 343. Given the potential for error, it was decided to collect a sample of 350 participants. The stratified random sampling technique was used to collect the sample, with Kerala divided into three strata: north, central, and south. At least three clinics were randomly selected from each region, based on the ICMR (Indian Council of Medical Research) list of clinics in Kerala. The inclusion criteria included women who (a) were married and did not have a living child and were undergoing IVF-ET treatment; (b) were aged between 20 and 45 years; and (c) were able to communicate in Malayalam or English. Women with mental disorders or cognitive impairment were excluded. Each clinic was followed up on for 4 months. Each month, data on participants undergoing IVF were collected with the help of nurses, and at least 9-10 participants were randomly allocated to the sample. A total of 39 participants were selected randomly from each clinic. If anyone declined to participate, another participant from the list was chosen by lottery.
Ethical consideration
This study underwent a comprehensive review and received approval from the Institutional Ethical Committee. Informed consent was acquired from both the clinic authorities and the participants involved in the study. Throughout the data collection and management process, confidentiality was rigorously maintained. All participants were informed that their participation was entirely voluntary, and they retained the right to withdraw from the study at any point without any repercussions. Additionally, measures were implemented during the data coding, entry, analysis, and report writing processes to ensure that individual participants remained unidentifiable, thereby safeguarding their anonymity
Measures
1. Personal data schedule
Personal and demographic details were collected using a personal data schedule that includes information about age, religion, education, occupation, and cause of infertility.
2. Fertility quality of life (FertiQol) questionnaire
The FertiQoL,[12] is a Likert scale designed to assess QoL across six subscales, such as emotional well-being, mind-body connection, marital relationships, social interactions, treatment tolerance, and environmental factors. Scoring for the scale is conducted using a 5-point system, with each item assigned a score ranging from 0 to 4. The Cronbach’s alpha coefficient for the FertiQoL scale was determined to be 0.921, signifying a high level of internal consistency.
3. Rosenberg self-esteem scale
Self-esteem is assessed using the Rosenberg self-etseem scale(RSES),[13] a widely recognised tool used around the world. In this study, the Malayalam version of RSES was employed, which demonstrated a Cronbach’s alpha reliability coefficient ranging from 0.83 to 0.89.[14]
4. Coping strategy scale
This study employed the Copenhagen Multicentre Psychosocial Infertility (COMPI) Coping Strategy Scale,[15] a 19-item instrument designed to assess the frequency of various coping strategies utilised by infertile women in response to specific fertility-related pressures. The COMPI scale has four subscales: 1. Active-Avoidance Strategy, 2. Active-Confronting Strategy, 3. Passive-Avoidance Strategy, and 4. Meaning-Based Coping Strategy. The internal consistency of the subscales was evaluated using Cronbach’s alpha, yielding values of 0.68, 0.76, 0.46, and 0.59 for the subscales, respectively. The Malayalam version of the questionnaire used for the study was adapted and standardised by the researcher.
Statistical analysis
Statistical analysis was conducted using IBM SPSS version 24. To investigate the relationships among self-esteem, the four coping strategies, and FertiQoL, Pearson product-moment correlations were calculated. To assess the mediating effects of coping strategies on the association between self-esteem and FertiQoL, a bootstrapped mediation analysis was conducted using the software PROCESS macro (model 4) developed by Hayes.[16] This bootstrapping method is recommended as it is deemed more appropriate than traditional mediation approaches for models that encompass multiple potential mediators.[17,18]The procedure involves repeatedly sampling cases from the original data set, specifically 5,000 times in this instance due to the limited sample size. A 95% confidence interval (CI) was employed in these analyses. A mediator variable is regarded as significant if the obtained CI does not include the value of zero.[16] In this study, the inclusion criterion for conducting the bootstrapped mediation analysis dictated that the potential mediator must exhibit bivariate characteristics and demonstrate significant correlations with both the independent variable (self-esteem) and the dependent variable (FertiQoL).
RESULTS
Table 1 presents the demographic characteristics of the sample. Mean age of the sample is 31.91 (4.856). Regarding educational qualifications, 77.8% of participants had earned undergraduate or post-graduate degree, 15.6% completed their higher secondary education (equivalent to “plus two”), and 6.6% finished tenth grade. 59.8% of participants were working in various sectors, including professional, semi-professional, clerical, business, and skilled jobs; 40.2% of the women were homemakers responsible for managing household duties, 37% were diagnosed with female factor infertility, 13.3% with male factor infertility, 27.2% with combined factor infertility, and 22% with unknown causes of infertility.
| Demographic variables | Mean and SD |
|---|---|
| Age (Mean and SD) | 31.91 (4.856) |
| Education | Percentage (%) |
| Tenth level | 6.6 |
| Plus two levels | 15.6 |
| Degree | 47.7 |
| PG and above | 30.1 |
| Employment status | |
| Employed | 59.8 |
| Unemployed | 40.2 |
| Cause of infertility | |
| Female factor | 37 |
| Male factor | 13.3 |
| Combined factors | 27.2 |
| Unknown factors | 22.5 |
| Duration of treatment | |
| 1-3 years | 50.9 |
| 4-7 years | 29.5 |
| 8-10 years | 10.7 |
| Above 10 years | 9.0 |
SD: Standard deviation
Table 2 presents the Pearson correlation coefficients for the variables under investigation. Self-esteem exhibits a positive correlation with both FertiQoL and meaning-based coping. In contrast, self-esteem demonstrates a negative correlation with active avoidance coping and active confronting coping.
| Variables | 1 | 2 | 3 | 4 | 5 |
|---|---|---|---|---|---|
| 1. Fertility quality of life | (-) | ||||
| 2. Self-esteem | 0.678** | (-) | |||
| 3. Active avoidance coping | -0.313** | -0.275** | (-) | ||
| 4. Active confronting coping | -0.345** | -0.233** | 0.32** | (-) | |
| 5. Passive avoidance coping | -0.036 | -0.001 | 0.436** | 0.208** | (-) |
| 6. Meaning-based coping | 0.502** | 0.474** | -0.021 | -0.135* | 0.346** |
There exists a positive relationship between active avoidance coping and active confronting coping. Active confronting coping is positively correlated with passive avoidance coping and negatively correlated with meaning-based coping, while a significant positive association is observed between passive avoidance coping and meaning-based coping. FertiQoL is negatively correlated with both active avoidance coping and active confronting coping, while it retains a positive relationship with meaning-based coping. Passive avoidance coping does not display a significant relationship with either FertiQoL or self-esteem; consequently, it is excluded from the mediation model.
Mediating effect of coping strategies on the association between self-esteem and FertiQoL
Active-avoidance coping, active-confronting coping, and meaning-based coping were the proposed mediators that met the inclusion criteria and were included in the bootstrapping mediation analysis. Assumptions of regression, such as linearity, independence, normality of residuals, and homoscedasticity, were checked and found within acceptable limits. Table 3 presents the findings of this mediation analysis (PROCESS Model 4), including the direct, indirect, and total effects of significant factors on the FertiQoL among women preparing for IVF. The overall model accounted for 50.8% of the variance in FertiQoL outcomes when age, education, employment, and duration of infertility treatment were included in the model as covariates.
Figure 1 depicts the path coefficients of active avoidance, active confronting, and meaning-based coping in the mediation model. Self-esteem is significantly associated with active avoidance coping, β = -0.1205, SE = 0.0226, t (346) = -5.3431, p <0.01, 95% CI [-0.1649 -0.0761]. The standardised coefficient was β = -0.2907, suggesting a negative relationship between self-esteem and active avoidance coping. Self-esteem is also significantly associated with active confronting coping, β = -0.1208, SE = 0.0345, t (346) = -3.5056, p <0.01, 95% CI [-0.1886, -0.0530]. The standardised coefficient was β = -0.1947, suggesting a negative relationship between self-esteem and active avoidance coping. Self-esteem was found to have a significant positive association with meaning-based coping (β = 0.2608, SE = 0.0280, t(346) = 9.3246, p <0.01, 95% CI [0.2058- 0.3158], β = 0.4655). Active avoidance coping is a significant negative predictor of FertiQoL, β = -0.7305, SE = 0.3430, t (346) = -2.1296, p <0.05, 95% CI [-1.4052- -0.0537]. The standardised coefficient was β = -0.089. Active confronting coping is a significant negative predictor of FertiQoL, β = -0.8833, SE = 0.2064, t(346) = -4.2804, p <0.01, 95% CI [-1.2893- -0.4774]. The standardised coefficient was β = -0.1610. Meaning-based coping is a significant positive predictor of FertiQoL (β = 1.5835, SE = 0.2708, t(346) = 5.8467, p <0.01, 95% CI [1.0507, 2.1162], β = 0.2607).
Table 3 shows the summary of the direct, indirect, and total effects of significant factors on the FertiQoL among women preparing for IVF. When coping strategies were included in the model, the total effect of self-esteem on FertiQoL was significant, b = 2.2454, SE = 0.1363, t(346) = 16.4782, p <0.001, 95% CI [1.9774, 2.5135]. The standardised total effect was β = 0.6596, representing a moderate effect size. The direct effect of self-esteem on FertiQoL also remained significant, b = 1.6343, SE = 0.1487, t(346) = 10.9940, p <0.001, 95% CI [1.3419, 1.9267]. The standardised direct effect was β = 0.4803. This suggests that self-esteem continues to uniquely contribute to FertiQoL, independent of its effect through coping strategies. The indirect effect of self-esteem on FertiQoL through coping strategies was also statistically significant, b (total indirect effect) = 0.611, with a bootstrap standard error of 0.1041 and a 95% bias-corrected CI of [0.4147, 0.8285]. Since the confidence interval did not include zero, the indirect effect was considered significant. The completely standardised indirect effect was β = 0.1796. A 95% bias-corrected bootstrap CI for the indirect effect for active avoidance coping, active confronting coping, and meaning-based coping is mentioned in Table 3. The results indicate that coping strategies, such as active avoidance coping, active confrontation coping, and meaning-based coping, partially mediate the relationship between self-esteem and FertiQoL. The completely standardised effect, denoted by β, represents the effect size that determines how many standard deviations the dependent variable (QoL) will change for a one-standard-deviation change in the independent variable (self-esteem), with the intervening variable (coping strategies) mediating this effect. Among the coping strategies, meaning-based coping was found to have a higher β value (0.1214), followed by active confronting coping (0.0314) and active avoidance coping (0.0259). The result indicates that meaning-based coping strongly mediates the relationship between self-esteem and QoL compared to active confronting and active avoidance coping.
| Variable | Effect | b | Standard error (SE) | t- value | p value | 95% Bias-corrected bootstrap CI | β | |
|---|---|---|---|---|---|---|---|---|
| LLCI | ULCI | |||||||
| Fertility quality | Total | 2.2454 | 0.1363 | 16.4782 | <0.001 | 1.9774 | 2.5135 | 0.6598 |
| Direct effect | 1.6343 | 0.1487 | 10.994 | <0.001 | 1.3419 | 1.9267 | 0.4803 | |
| Indirect (total) | 0.6111 | 0.1041 | 0.4147 | 0.8285 | 0.1796 | |||
| Active avoidance of life | 0.088 | 0.0439 | 0.0072 | 0.1829 | 0.0259 | |||
| Active confronting | 0.1067 | 0.0409 | 0.0354 | 0.1963 | 0.0314 | |||
| Meaning-based coping | 0.413 | 0.0932 | 0.2409 | 0.6044 | 0.1214 | |||
LLCI: Lower limit confidence interval, ULCI: Upper limit confidence interval, CI: Confidence interval, IVF: In vitro fertilization, p value of total effect: <0.001
DISCUSSION
This study examines the complex relationship between self- esteem, coping strategies, and FertiQoL among women preparing for IVF. It specifically investigates the mediating role of coping strategies in the association between self-esteem and the FertiQoL. The findings indicate a significant positive correlation: higher levels of self-esteem are associated with an enhanced QoL for women undergoing IVF treatment. This outcome is consistent with previous research, which has demonstrated that as self-esteem increases, the quality of life related to fertility also improves markedly.[19] In the context of chronic stressors such as infertility, self-esteem serves as a critical protective factor against psychological distress, including anxiety and depression, thereby contributing to an overall improvement in QoL.[19,20] Additionally, self-esteem is closely linked to psychological resilience, which entails the ability to respond positively and adapt successfully to challenging situations.[21-23]
This research emphasises the importance of fostering self-esteem and developing effective coping strategies as crucial elements in supporting women throughout their IVF journeys, ultimately promoting QoL.
Among coping strategies, both active avoidance coping and active confrontation coping have been found to negatively mediate the relationship between self-esteem and FertiQoL. This suggests that low self-esteem may lead to the use of these coping strategies, which in turn result in a decline in QoL. Among women with fertility issues, avoidance strategies might reflect a lack of confidence in facing discussions about pregnancy and children. While these avoidance strategies can provide temporary distraction and relief from mental pressure, they are often not beneficial in the long term and may worsen feelings of helplessness, reduce self-confidence, and ultimately lower the FertiQoL. This finding aligns with research conducted by Jing et al.[24]
Active confrontation coping, which integrates problem-focused and emotion-focused strategies, such as seeking informational support, engaging in emotional processing, and expressing feelings, can be viewed as an adaptive coping strategy in various contexts. The results of the present study do not support this view. According to Folkman,[8] the effectiveness of a particular coping strategy depends on the match between the strategy and the controllability of the situation. Given that IVF-ET treatment is an exceptionally complex and uncontrollable process with often uncertain outcomes, too much indulging in active confronting strategies might be counterproductive for the infertile women. Their efforts to manage treatment actively might lead to feelings of frustration and disappointment, which are likely to have detrimental effects on their QoL. Jing et al.[24] also reported a negative association between active confronting coping strategies and FertiQoL among women in the IVF treatment.
The findings indicate that a meaning-based coping strategy functions as a positive mediator between self-esteem and FertiQoL, which is found to have a higher β value compared to the other two coping strategies. This suggests that meaning-based coping mediates the relationship between self-esteem and FertiQoL. Infertile women who address the challenges associated with infertility by seeking meaning, engaging in positive reinterpretation, and fostering growth within the context of childlessness demonstrate improved self-esteem and enhanced FertiQoL. The adoption of a meaning-based coping strategy allows individuals to reframe their situations, thereby identifying new sources of support and guidance that enhance both self-esteem and overall QoL. These results are consistent with prior research demonstrating that meaning-based coping has a beneficial impact on the enhancement of FertiQoL among women facing infertility.[24,22]
This evidence highlights the importance of fostering a sense of meaning and understanding during challenging experiences, indicating that such an approach can significantly influence personal well-being and resilience.
Individuals with higher self-esteem tend to employ positive emotional coping strategies, including self-love, self-acceptance, cognitive reappraisal, and psychological growth. These strategies enhance an individual’s internal capacity to effectively manage adversity, enabling them to choose constructive and adaptive approaches over passive or harmful responses. This relationship suggests that self-esteem is not merely correlated with improved coping choices; it is, in fact, a critical prerequisite for the successful implementation of adaptive strategies. Low self-esteem is often linked with maladaptive responses, such as self-blame and mental rumination, which can hinder the therapeutic process and impede progress. Therefore, it is imperative that efforts to improve self-worth accompany or precede specialised training in coping skills to maximise overall effectiveness. In this framework, high self-esteem positively influences both primary appraisal, where individuals evaluate the threat associated with infertility challenges, and secondary appraisal, which pertains to the assessment of one’s ability to manage these challenges. Thus, self-esteem functions as a crucial psychological resource that guides the selection of coping strategies. The effectiveness of these strategies ultimately determines adjustment outcomes, particularly with regard to FertiQoL. Consequently, the proposed model highlights that self-esteem facilitates adaptive coping, resulting in an enhanced FertiQoL.
Clinical implications
The substantial theoretical and empirical support for the mediation model suggests that clinical interventions designed to enhance FertiQoL should adopt a dual focus: enhancing internal resources, specifically self-esteem, and refining adaptive mechanisms, such as coping strategies. Self-esteem is recognised as a critical foundational component that mental health professionals must consider when providing care for individuals experiencing infertility. A high level of self-esteem serves as a psychological buffer, alleviating feelings of self-blame and excessive rumination, and thereby facilitating the adoption of constructive coping strategies. By prioritising self-esteem and effective coping mechanisms, healthcare practitioners can develop impactful and supportive therapeutic interventions for patients facing the emotional and psychological challenges associated with infertility. Psychosocial interventions must be highly individualised, taking into consideration each patient’s coping strategies and personal needs. Such an approach should be systematically integrated within fertility centres to facilitate a comprehensive treatment experience.
The complexity of the mediation pathway necessitates a personalised approach that employs various therapeutic models, including cognitive behavioural therapy (CBT), mindfulness-based interventions, and positive psychological strategies, all tailored to the unique needs of women undergoing IVF treatment. CBT specifically addresses the cognitive errors, effectively challenging negative self-talk often linked to low self-esteem, and reframing maladaptive thought patterns. Positive psychotherapy focuses on fostering positive emotional experiences and leveraging individual strengths, which has been demonstrated to enhance life satisfaction in women during IVF treatment. Moreover, mindfulness-based interventions provide holistic relief from the physical manifestations of stress related to IVF, improving overall quality of life and encouraging greater emotional resilience. Collectively, these therapeutic strategies constitute a robust support framework that empowers women as they navigate the complexities of their fertility challenges.
Strengths and limitations
The study investigated women who are preparing for IVFET treatment, often perceived as the final option prior to adoption. The research emphasised the importance of QoL for these women, assessing the influence of self-esteem and coping strategies on it. The findings not only demonstrated potential improvements in FertiQoL among infertile women but also offered valuable direction for the development of psychological interventions during the infertility treatment process. Nonetheless, the study has its limitations. The study focused only on women; men were not included, and the results can be generalised only to the population analysed.
Future research should consider implementing intervention studies that focus on psychological strategies to enhance the QoL among individuals facing fertility challenges. Moreover, including male counterparts in such studies and exploring existing social support systems available to participants would provide a more comprehensive understanding of the factors influencing their experiences during this significant life event.
CONCLUSION
The evidence strongly confirms that coping strategies function as an important mediating role between a woman’s internal psychological resource (self-esteem) and her subjective adjustment outcome (FertiQoL) during IVF treatment. High self-esteem might act as a fundamental protective factor, predicting the selection of adaptive strategies, such as active confronting coping, active avoidance, and meaning-based coping, which can influence the QoL.
Author contributions:
TT, SVK: framed the study; TT: collected, analyzed the data, and drafted the manuscript; SVK: supervised and guided each and every step in the process, gave necessary clarification, and evaluated the drafted manuscript.
Ethical approval:
The research/study was approved by the Institutional Review Board at the ethical Committee, School of Behavioural Sciences, approval number SoBS/EC-3/2023, dated 23rd March 2023.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, and anonymity.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript, and no images were manipulated using AI.
Financial support and sponsorship: Nil
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