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Qualitative Study of Iranian Infertile Females


1 Department of Social Sciences, Yazd University, Yazd, Iran
2 Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
3 Infertility Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
*Corresponding author: Farnaz Rahnavard, Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran, E-mail: rahnavardf@sums.ac.ir.
Women's Health Bulletin. 4(1): e33490 , DOI: 10.17795/whb-33490
Article Type: Research Article; Received: Sep 30, 2015; Revised: Jan 16, 2016; Accepted: Jan 30, 2016; epub: Nov 5, 2016; collection: Jan 2017

Abstract


Background: Infertility is a complex phenomenon, which threatens everyone and every family. Females are threatened more due to various social differences.

Objectives: The goal of this study was to explore the experiences of infertile females, who had referred to a public center of infertility in Shiraz, Iran.

Methods: This was a qualitative study based on four focus groups and four in-depth interviews with 25 infertile females. Transcribed data were analyzed using conventional content analysis.

Results: Four themes were extracted from the data, which were life without excitement, social pressures, low self-esteem and treatment problems. Although it seems that these themes are variable, they present a total reality, which leads to a bitter life.

Conclusions: Infertile females are under multidimensional pressures involving psychological, social and economic aspects of their life and interpersonal relationships. This condition leads to a bitter situation for these people.

Keywords: Infertile Females; Experience; Stigmatization; Psychosocial Problem

1. Background


An important aim of family formation is having children. This is related to subjects such as parenthood experiences, as a major transition in human development (1), emotion dimension (2), and meaningful or profound emotion (3, 4). Also it has been shown that parents (especially fathers) report relatively higher levels of happiness and positive emotion than people without children (3). Therefore, the presence of children influences multidimensional aspects of one’s life. It is not an exaggeration if it is said that parenthood experience is unique. Due to the mentioned points, fertility is the main function of every family. Because of the significance of infertility, it is considered a globally important subject (5).


Infertility is ‘a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse’ (6). It is a phenomenon like fertility. However, it is an undesirable situation (7), which is at once a medical, psychological and social problem (8). It is a biological defect, which leads to diverse psychosocial problems such as sadness, depression, anger, confusion, desperation, hurt, embarrassment and humiliation (9). Also, it includes diverse social problems such as social suffering in developing countries (10), and stress from the management of infertility (11). Social problems such as lifestyle changes, various physical and emotional changes, and changes in their relationships are the results of this phenomenon (12). It is also related to economic problems, which threatens families (13).


Infertility is defined as a health problem around the world (14) including the Muslim world (15). In Iran, it seems that almost 21% - 22% of Iranian females experience primary infertility at some time during their married life (16). A systematic review showed that the average rate of infertility is 10.9%, primary infertility is 10.6%, secondary infertility is 2.7%, and current infertility is 3.3% (17).


There are several studies, which were done among infertile females. It was shown that infertility influences the sexual and emotional relationship between partners. Also, it was shown that infertile couples have some unmet expectations from treatment personnel (1). Also, other studies showed that abuse, family instability, social exclusion and low self-esteem are general experiences of infertile females (1). Other studies showed that infertility is associated with social stigma (3) and emotional and economics issues (4). Although these studies are about the experience of infertility, yet qualitative studies are profoundly dependent on context.

2. Objectives


As there are no studies about infertility in Shiraz and because of the importance of the issue, the aim of this study was to explore the infertility experience of infertile females in this area.

3. Methods


This was a qualitative study, which was done from January to June 2015. Data were gathered from 25 infertile females, who participated in four focus groups and four in-depth interviews at a public infertility research center in Shiraz, Iran. The main question in these interviews was about their life experience of childlessness and their problems during the treatment.


Sampling was done purposefully. A Gynecologist selected the samples after talking to them and obtaining their consents. There were no limited criteria and all the infertile females with different demographic characteristics participated in the study. The criterion for stopping the data gathering was saturation. The study was saturated with 25 participants. Data was recorded and transcribed. After reading the data, defined meaning units, extract codes and explored themes with reflexive manner were used to explore the quality of infertility. Transcribed data were analyzed based on conventional content analysis (18). The research was done according to the Helsinki declaration of ethical issues (19). The study was approved by the certification of the ethics committee of Shiraz University of Medical Sciences and verbal consent was obtained during data gathering. Because of ethical obligations and consideration of ethical issues during data gathering and analysis, the names of the participants in this study were fabricated and researchers concealed their real names.

4. Results


Twenty-five females participated in this study. Results showed that minimum age of participants was 21 and maximum age was 48 years old. Mean age was 32.90 years old with standard deviation of 6.95. Number of years after marriage was at least one and highest number of years was 20. The minimum years of living with infertility was one year and maximum was 20 years, which is equal to years after marriage.


Table 1.
Characteristics of Participants

The results showed that infertility was a bitter experience for the participants. This experience includes four dimensions: life without excitement, which is related to quality of life; low self-esteem, which indicates the bad judgment of one self; social pressure, which is related to negative social experiences; and therapeutic problems, which are related to problems in the treatment modality.


4.1. Life Without Excitement

Childlessness is a bitter experience, which affects the quality of life of females. According to the participants, childlessness means life without emotional action or motivation. Life in this situation has various difficulties. Since the main aim of marriage is responding to parenthood needs, infertility suppresses this need and life takes a routine situation without excitement. Before and after marriage, every woman has a plan for future experiences and thinks about raising a child. Childlessness is a difficult experience indicating that she cannot achieve these important goals.


Childlessness means lack of fun and companion. Infertile females feel lonely. They don’t have anyone to talk and work with. They don’t know what to do because they feel they are wasting their time. On the other hand, when there is no one at home, it is quiet and this threatens the internal and psychological aspects of their life.


Life is very dull and monotonous (34-year-old female).


In this situation the woman may occupy herself with another job.


Sometimes not having a child is very terrible. My husband bought some birds to occupy me with them. If I had a child I could talk to him/her. I would teach him/her how to walk (30-year-old female).


The status of working women is better than housewives. They are busy for at least one shift. However, they are faced with the same problems when they come back home.


So long as I’m at work it’s good and I keep occupied. When I come back home, I say if we have a child, we could play with the child and take him/her to the park (38-year-old female).


4.2. Low Self-Esteem

Pregnancy has an important status for a woman after marriage. Also, it has psychosocial functions. The first expectation of marriage is fertility and having children. When infertility occurs, the woman thinks she has lost her main function that is being fertile. Therefore she feels defeated. This leads to a reduction in her self-esteem.


I had a false self-esteem before I knew I’m infertile and I had confidence in myself. Now I feel I’ve failed. I’m very sad when I see my relatives, who can become pregnant easily but I cannot (28-year-old female).


Infertility for participants means losing the main plan of their life. An individual can have a job and economic autonomy. However, they get married to have children. Infertility ruins such plan.


I became very sad because I just got married to have children. I had stood on my own feet during my life. I lived like a man, but now living is very difficult. I think about my infertility all the time (46-year-old female).


A decrease in self-esteem is also related to social pressures and stigmatization. On the other hand, infertile females experience low level of self-esteem because of the attitude and behavior of other people towards them.


Whenever other people don’t know I don’t have children, I have higher self-esteem. However, when people become aware of this problem, I lose my self-esteem. Thus I can’t attend weddings and funerals (37-year-old female).


Menstruation is the worst time during which self-esteem decreases. Infertile females are expected not to have menstruation, but when it starts, their self-esteem is decreased.


Every month when my period starts my self-esteem decreases to half the usual level (27-year-old female).


4.3. Social Pressure

Another extracted theme was social pressures. What people say, their views and behaviors about infertile females have a negative effect on them. Infertility and childlessness involves social pressures, which prevent coping strategies towards infertility. This theme has two subthemes, which are stigmatization and social isolation.


Due to the importance of children in life, every female after marriage is asked by other females, relatives and friends these types of questions: Are you pregnant? Why aren’t you pregnant? Do you have any problems? Do you want me to introduce you to a doctor for treatment? When a woman feels she is infertile, these types of questions have a lot of negative effects.


What people say makes me feel worse. I calm myself. My husband consulates me, but when people talk to me about children, all of my efforts become vain, and I become sad (44-year-old female).


Sometimes social labeling has a very bad influence. It seems it is related to some feminine characteristics such as jealousy and envy.


Some people tell us, even cows deliver a child. There are younger women than you with four or five children and you don’t even have one. Their words are worse than one hundred gun shots. They shatter my heart (27-year-old female).


As these statements show, stigmatization is a bad experience for infertile females. Another issue faced by infertile females is social exclusion.


Also, stigmatization makes a woman stay away from the society. In this experience, childlessness is labeled badly by others. Therefore, infertile females withdraw from the society and people. They don’t want to be among families, friends and relatives. They feel very lonely. Childlessness is a bad label that negatively affects infertile females.


Wherever we go, we are asked: ‘are you pregnant’? I cry a lot. My fragile heart gets hurt. We feel calm at our home. When we go out, people torture us (46-year-old female).


Infertile women don’t like to speak about their pregnancy. According to their remarks, when they are among people who know them, the main subject is their pregnancy. This is a common experience for them. These people don’t like this condition and therefore they isolate themselves from the society. It seems that these groups are ignored by the society and any gathering.


It seems that we are different types of people. When we are at a gathering and the women who have children, are abusive in their words. They don’t reply to our questions, and they don’t listen to what we say. It seems that their mind is elsewhere, they don’t pay attention to us. They are only with themselves (those who have children). They talk about unknown subjects, for which we don’t have an opinion to express (30-year-old female).


These statements show negative attitudes towards infertile females leading to their social isolation. Infertile females are excluded from the society.


Every time my husband goes out, I immediately go to my mother’s home because I don’t want anyone to come to our home and ask about my pregnancy (27-year-old female).


4.4. Therapeutic Problems

Another theme is related to therapeutic problems that infertile females and their families are challenged with. The long distance to treatment centers, fatigue, and difficult, ineffective and long-term treatment, lack of acceptance of the costs by the insurance system and appointment reservation are the main problems. Therapeutic problems are generally divided to two subcategories: economical and interpersonal (patient-providers) relationships.


Since infertility treatment in Iran is very expensive, all the participants are worried about the costs. For example Rahele said: “The costs of infertility treatments are high. The insurance company does not accept them. Our income is low’. Providing the costs of treatment was difficult for most of the participants. Some of them got a loan from banks or borrowed money from their relatives such as their father; some of them sold their ornaments, and some of them covered the costs by limiting the necessities of their life.


My husband doesn’t have any money. I paid all the treatment costs. I borrowed money for IVF. My father helped me financially before this procedure (45-year-old female).


High cost of treatment places much pressure on families, especially on those with unsuccessful treatment. In this condition, husbands suppressed their wives and this caused psychological problems for the females.


I had many economic problems. My husband complains about the amount of money he has to spend on me. I cry all the time (30-year-old female).


Poor patient-provider relationship is another problem associated with treatment. Disregarding the difficulties of patients, incomplete appointments, and doctors’ uncertain answers to patients are the main issues. Of course, this is a general problem for all patients; however these patients think they are exceptional because of their specific problems. They expect healthcare professionals, specifically doctors, nurses and secretaries to pay more attention to them. Many of the complaints are related to doctor’s secretaries in order to make an appointment.


They [secretaries] don’t guide correctly. They are impatient. For example, after a month they gave me an appointment, we traveled a long distance and they said the doctor isn’t coming today. They didn’t contact me before (37-year-old female).


These statements confirm that secretaries do not pay attention to the importance of patients’ problems. The other participants had similar dissatisfaction with secretaries or nurses.


The clinic has very impatient secretaries. Nurses don’t have good enactment. The secretaries don’t give appointments that are scheduled soon (32-year-old female).


The other poor interpersonal relationship was dissatisfaction of doctor-patient interactions. Lack of correct and decisive answers from the doctor lead to uncertainty and also change of doctor.


I was visited by all doctors for two to three years. A doctor prescribed me a color photo. Another one said it’s not needed. After doing sonography, my general condition became bad on the street, on my way home. Previously, they did not tell me that I needed someone to accompany me after the procedure. I did not know how it is done (29-year-old female).


Patients expect doctors to pay more attention to them. Due to the high cost of the treatment and importance of fertility for them, these patients expect doctors to consider them more important.

5. Discussion


This study aimed to explore the experience of infertility among infertile females, who were referred to a public infertility center in Shiraz. The results showed that infertility includes some virulent experiences for all the participants. One negative experience was life without excitement, which is a cognitive view to life. This theme is closely related to childlessness of infertile females. Although other studies showed stigmatization of childlessness among infertile couples (14, 20) and this study confirmed it, yet outstanding findings of this study are related to psychological problems of childlessness. Infertile females are discouraged, desperate and their life passes monotonously. Their lives are not fun. This finding is related to psychological problems such as anxiety, depression, anger, confusion, desperation and hurt, which were confirmed by other studies (9, 21-23).


On the other hand, the results showed that females develop a low self-esteem. Since they feel they have lost an important feminine function, they lose their self-esteem. This finding was confirmed by other studies (24-26). However, it is one of the predictors of infertility distress (25) and can reduce their distress (27).


Regarding the social pressure of infertility, other studies confirmed social stigmatization (14) and social isolation (26). Part of the social pressure for infertile females is cultural. An important point is that infertile females can cope with their psychological problems, but social problems make different situations for them. On the other hand, we can say many of the psychological problems are rooted in social stigmatization and isolation. For example, if infertility was accepted by others, in a cultural context, the psychological problems of infertile females could be decreased.


Another extracted theme was about treatment problems. This theme was not extracted in other studies. However, it is clear that infertility treatment is costly (28). Many of our participants complained about the high costs of treatment and low considerations of insurance systems regarding this problem. This subject becomes more important when first or second therapy fails. On the other hand, patient-provider relationship is another problem in the treatment path, which was explored by the other studies (29). Infertile females need greater consideration by secretaries and nurses on one hand and doctors on the other. Good and appropriate interaction with patients and giving adequate and transparent explanation to the patient about the disease and the treatment are important needs in this area.


As one research indicated infertile females are challenged with multiple problems. Therefore, they need family counseling (7). Also, they need to be educated with cognitive coping strategies and goal adjustment (30). Another study indicated that coping technique training helped increase the use of coping strategies for self–control, seeking social support, accepting responsibility, planning for complete problem solving, positive reappraisal and decreasing of the use of escape–avoidance coping in infertile females (31). Infertile couples can use virtual space to reduce their problem of social isolation (32).


Generally, the problem of infertility in this study can be divided to two groups; personal and social. Life without excitement and low self-esteem are personal. Social pressure and treatment problems are social. These experiences are related to each other. This means that personal problems reduce capability of infertile females in facing social problems. Also, facing social problems amplifies personal problems.


5.1. Implication

The results showed that infertile females are a marginalized group with several problems. Based on the results of this study, policymakers should consider two kinds of infertility problems. On one hand, they should provide psychological consultation for these people to promote their personal motivation and self-esteem. On the other hand, they should consider solving social pressures of infertility with desensitization in the society by using mass media, context of schools and universities. Furthermore, policymakers should address two main problems, faced by infertile females during treatment courses.


5.2. Conclusion

Infertile females have bad experiences during their lifetime. The results showed that these people are under multidimensional pressures, which are psychological, social, economic, and interpersonal relationships. This condition leads to a bitter situation in their life. The study showed that this group is under social pressure so they can’t have any coping strategies. Thus, it is suggested to support this group, mentally, socially and culturally.

Footnotes

Authors’ Contribution: Ahmad Kalateh Sadati designed the study and wrote the manuscript. Faranza Rahnavard and Bahia Namavar Jahromi were the consultants of the study and gathered the data.
Funding/Support: This research was supported by a Grant (No. 01-50-8790) from the Infertility Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.

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Table 1.

Characteristics of Participants

Age Years After Marriage Years With Infertility (Finding Out the Problem)
N 25 25 25
Mean 32.90 6.45 5.45
Std. Deviation 6.951 4.925 5.166
Minimum 21 1 1
Maximum 48 20 20