ORIGINAL ARTICLES: INFERTILITY

Adversities of being infertile: the

experience of Jordanian women
Salwa Obeisat, R.N., D.N.Sc., Muntaha K. Gharaibeh, R.N., Ph.D., Arwa Oweis, R.N., D.N.Sc.,
and Huda Gharaibeh, R.N., Ph.D.
Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan

Objective: To describe and interpret the experiences of and adversities faced by infertile Jordanian women as described from their own
perspectives.
Design: A qualitative descriptive design.
Setting: The women were interviewed at a nonprofit women's organization in the north of Jordan. The organization focuses on em-
powerment and health issues.
Patient(s): This study included a purposive sample of 25 infertile Jordanian women who were unsuccessfully trying to conceive for
a minimum of 1 year, and who were receiving treatment for infertility.
Intervention(s): Face-to-face, in-depth, semistructured interviews were conducted, audiotaped, and transcribed using thematic
analysis.
Main Outcome Measure(s): Outcomes were measured using thematic analysis of the interview transcripts.
Result(s): Four key adversity themes emerged from the data: the adversity of incomplete being, the social adversity of being infertile,
the adversity of another wife, and the adversity of changes in the marital relationship.
Conclusion(s): Jordanian women are seriously affected by infertility and experience personal, social, and marital adversities, which
affect their well-being. These adversities need to be conceptualized within a framework that
can be used to empower and counsel infertile women in all aspects of life. (Fertil SterilÒ Use your smartphone
2012;98:444–9. Ó2012 by American Society for Reproductive Medicine.) to scan this QR code
Key Words: Infertility, adversities, Jordanian women, experience and connect to the
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I
nfertility is a worldwide health enced to a large degree by religion and licly disclosed; and 3) more attention is
problem that profoundly impacts the social norms concerning marriage, given to ‘‘high’’ fertility in the non-
the lives of both men and women. divorce, and family organization (1). Western world, which fails to regard
Globally, 10%–15% of couples of Although several studies have been infertility as a significant priority (5, 6).
childbearing age experience infertility conducted on reproduction and certain Infertility interferes with all aspects
(1, 2). According to the World Health aspects of infertility, it continues to be of a couple's relationship and presents
Organization, about 80 million people overlooked as a public health issue, a major life challenge to those who
in the world live with infertility (3). In especially in developing countries (5). desire children (2). It impacts the health
many cultures around the globe, the Several reasons for this have been and well-being of individuals, couples,
inability to conceive and the resulting identified: 1) infertility is most often and society as a whole. The burden of
childlessness are often highly stigma- considered a private individual medical infertility includes psychological, so-
tizing, leading to profound social condition; 2) reproductive failure, espe- cial, and physical consequences, such
suffering for infertile couples (4).The cially male failure, is a taboo subject as anxiety, depression, helplessness,
perceptions of childlessness are influ- disguised in stigma and often not pub- marital intimidation, abandonment,
economic hardship, social stigma,
social isolation, and physical violence
Received January 1, 2012; revised April 3, 2012; accepted April 24, 2012; published online May 26, (2, 5, 7–9). Although consequences of
2012.
S.O. has nothing to disclose. M.K.G. has nothing to disclose. A.O. has nothing to disclose. H.G. has
infertility vary in nature and severity
nothing to disclose. between developing and developed
Supported by Al Al-Bayt University, Mafrak, Jordan. countries, people in developing coun-
Reprint requests: Salwa Obeisat, R.N., D.N.Sc., Faculty of Nursing, Jordan University of Science and
Technology, P. O. Box 3030, Irbid, Jordan (E-mail: smobeisat@just.edu.jo). tries are more severely affected by the
devastations of infertility due to its
Fertility and Sterility® Vol. 98, No. 2, August 2012 0015-0282/$36.00
Copyright ©2012 American Society for Reproductive Medicine, Published by Elsevier Inc.
higher prevalence and the pater-
doi:10.1016/j.fertnstert.2012.04.036 nalistic social norms (5, 7).

444 VOL. 98 NO. 2 / AUGUST 2012


In most areas of the world, women's well-being appears to
be more seriously affected by infertility than that of men (10).
In developing countries, including Jordan, the role or status of
women is defined by their reproductive capacity, and having
children is a woman's only chance to improve her status in so-
ciety and within the family (8). Conversely, infertility creates
significant social repercussions for women, including
unstable marriages, domestic violence, stigmatization, and os-
tracism (6, 11–13).
Jordan is predominantly Muslim with a population of
6 million, and a population growth rate of 2.3%. The total
fertility rate in Jordan is considered high despite a decline
from 7.3% in 1975 to 3.8% in 2009 (14). In recent years, infer-
tility has become an obvious reproductive health problem en-
countered by many Jordanian couples. All infertility treatment
technologies are available in Jordan. Assisted reproductive
technologies (ART) are acceptable, allowed, and encouraged
by Islam, especially because adoption is not an acceptable so-
lution (15). Islam has guiding principles for the use of ART—it
should be practiced only by married couples, within the con-
text of a valid marriage, and performed by a competent medical
team. The use of donor sperm, egg, and embryo is not accept-
able and, in fact, condemned by Islamic law (15–17). Despite
the availability of these treatments and their advanced
technologies, infertile couples in Jordan bear the financial
burden of treatment as only infertility investigations and
tests are covered by the health insurance system.
There are few statistics regarding the infertility rate in
Jordan. However, available statistics are limited to the num-
ber of successful IVF trials and are reported for different infer-
tility treatment centers. In addition, studies about infertility
among Jordanian women and its psychological implications
are lacking. Therefore, in this study, we aim to describe and
interpret the experiences of Jordanian women with regard
to infertility from their own perspectives as the first step to
understanding their suffering. Findings of this study are of
great relevance and importance for all health professionals
in practice settings and in the community and are important
for establishing strategies to counsel and support infertile
couples coping with these problems.
MATERIALS AND METHODS
Design
A qualitative descriptive approach was used with semistruc-
tured, in-depth interviews to describe the adversities faced
by infertile women. This approach permitted Jordanian
women to verbalize their own feelings and experiences and
to provide the subjective data necessary for understanding
the context of their experience.
Participants
A purposive sample of 25 infertile Jordanian women was used
to accurately describe their experiences. Participants were
recruited from a nonprofit organization in the north of Jordan
that focuses on women's empowerment and health issues.
Inclusion criteria were: women who had been trying unsuc-
cessfully to conceive for a minimum of 1 year regardless of
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Fertility and Sterility®
whether she or her husband were responsible for the problem,
and who were receiving treatment for infertility. Only women
under treatment were selected due to the cultural sensitivity
of this issue—women could not be approached unless they
were seeking treatment.
The participant's average age was 31.8 years (range,
19–40 years). The average length of marriage was 10.5 years
(range, 2–20 years). About 39% of participants had a college
or university education, whereas 60.9% had a high school ed-
ucation or less. Most of the participants were unemployed
(58.3%). The majority of couples (73.9%) had waited 1 year
or more after marriage to start fertility investigations,
whereas 26.1% started medical investigations within less
than 1 year. Fertility investigation in the interviewed sample
was initiated by women in 65% of cases, by both partners in
25% of cases, and by men only in 10% of the cases. Seventy-
six percent of the participants had medical insurance; of
those, only 10% had insurance that covered infertility
treatments. The responsibility for infertility was ascribed to
the woman (54.2%), the man (25%), both partners (16.7%),
or unknown (4.2%).
Procedure
All women were first identified with the help of the nonprofit
organization director who served as liaison between the
women and the researchers. The women were then contacted
by the researchers and asked to voluntarily participate in the
study. Before the interview, each woman was briefed on the
purpose of the study and was asked to consent to the study.
All interviews were conducted face-to-face in a quiet private
room at the women's nonprofit organization using in-depth,
semistructured interviews. Participants were asked to respond
to the main question—‘‘Tell me how you feel about being
unable to conceive naturally and about being infertile’’—
and other probing questions. Women were encouraged to
talk and to express their feelings, perceptions, and thoughts
of their experience. A pilot study was conducted on four
women to assist the researchers with the data collection pro-
cedure and to determine how to address the research question
and clarify details.
All interviews were conducted in Arabic. Each interview
was tape recorded and lasted between 30 and 45 minutes.
Data collection lasted for about 15 months (April 2006–July
2007). The length of the interview varied according to the
stage of saturation and the emergence of new themes. Signif-
icant themes were well established and validated by their
repetitive nature.
Ethical Considerations
The study was approved by the Ethical Committee of the
Faculty of Research Studies at Jordan University of Science
and Technology and the Ethical Committee of the Research
and Graduate Studies Faculty at Al Al-Bayt University (the
funding institution). All women consented in writing to
participation and to allow the researchers to make follow-
up contact to confirm the components and interpretation of
data analysis.
445
ORIGINAL ARTICLE: INFERTILITY
All women were assured of anonymity and confidential-
ity and that they had the right to withdraw from the study at
any time. Women were also informed that there were no risks
in participating in the study.
Transcribing, Translation, and Data Analysis
The researcher's recorded interviews were transcribed and
translated into English to minimize loss of data, and then
back-translated. Although the researchers tried to present
factual data during translation, they were also concerned
with the richness of the personal and cultural aspects of the
participant's experience. Data were analyzed using a thematic
content analysis (18). During data analysis and to ensure
consistency, all researchers met regularly during 4 months
to discuss and validate each of the steps of the analysis pro-
cess. First, data for each of the women were read several times
and their feelings, attitudes, and thoughts about infertility
were identified and carefully listed by all researchers indepen-
dently. The second step of analysis focused on the researcher's
explanations for the stated feelings and thoughts provided by
the women in which the meaning of these categories were
analyzed and integrated into a theme. In the third step, re-
searchers reached a consensus on the final categories (identi-
fied themes). These categories were defined with labels with
similar semantic content and a label that appropriately
represented the meaning of each category was attached to it.
Trustworthiness
The trustworthiness of the findings was maintained using
credibility, conformability, and transferability. Credibility
was ensured using the member checking approach: the re-
searcher returned the transcripts to five participants to verify
that the data and the interpretation of the findings reflected
the women's experience with infertility. Conformability was
ensured through the process of ‘‘bracketing,’’ whereby all
previous knowledge, beliefs, and common understandings
about a given phenomenon are set aside. Transferability
was established through ‘‘thick description,’’ in which detailed
descriptions of data with a rich mix of participant's quota-
tions were considered.
RESULTS
The study revealed four themes of adversities: the adversity of
incomplete being, the social adversity of being infertile, the
adversity of another wife, and the adversity of changes in
the marital relationship.
Adversity of Incomplete Being
The theme of adversity of incomplete being reflects the feeling
of women as failures to conceive, become a complete being,
and realize the family they always dreamt of. Women believe
that the purpose of marriage is to build a family and to be-
come mothers to satisfy their natural instincts and existence.
‘‘Getting married means creating a family and having
children, everyone likes to have children and each
woman after marriage keeps looking forward to be
446
a mother and I cannot. I want children who can say
mom, I want to raise them up and fulfill all their needs,
I want to feel useful and create a family.’’
‘‘To be a mother is the most important thing that any
woman wishes; childlessness is the biggest problem in
my life. We must create a family and have children,
my husband wanted children, and all of his brothers
have children but he does not have at least a child.’’
Women worry and feel anxious around their menstrual
time. The presence of menstrual blood is a constant re-
minder of their inability to become pregnant and a complete
being.
‘‘How can I forget? Every month, when I get my period,
I feel like screaming. I stay in my room crying when I do
not demonstrate the physical and symbolic signs and
changes of pregnancy.’’
Women who failed to conceive because of their husband's
infertility had similar feelings and live with a dilemma. They
hide the truth about their husband's infertility because they
do not want their husbands to be judged as an incomplete
being.
‘‘I never told my family that my husband is infertile
because this affects his masculinity and social status.
My husband can't adapt to this situation, he will have
the feeling of incompleteness, and people look at
infertile men as weak incomplete persons.’’
‘‘My husband is the one who is infertile, he suffers the
shame and humiliation of being incapable. Men cannot
accept this while women can accept it and hide the
suffering.’’
Women expressed their feelings that they are socially
stigmatized and labeled as being useless and having no pur-
pose in life and used metaphors for infertility.
‘‘People describe the infertile woman as a tree without
crops, which must be cut off from its roots.’’
Social Adversity of Being Infertile
The social adversities of being infertile reflect the women's
struggle with constant pressure and interference by their
social system. The pressure to conceive is mainly from the
husband's family and is directed toward the wife.
‘‘Wherever I go, my husband's family and friends ask
me questions such as: ‘Are you expecting anything
soon? When you will make us happy?’ The pressure is
on me, nobody asks my husband. I hate going out;
they make me miserable.’’
‘‘When people at work ask me how long we've been
married, I always answer that I have been married
only for one year rather than four to avoid their
questions.’’
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‘‘Even though my husband is the infertile one, his
friends and brothers told him that he can marry another
woman and God will give him children.’’
In most cases, women were badly treated by their
husband's families, usually by the mothers-in-law and
sisters-in-law, who insist that the husband should seek treat-
ment and even interfere with the couple's infertility treatment
decisions.
‘‘Each time I have my menstruation, my mother-in-law
stops talking to me; she keeps track of my menstrual
cycle. My sister-in-law keeps telling my husband that
he must get married to another woman with no need
to wait for treatment results.’’
‘‘My mother-in-law keeps asking, ‘What are you wait-
ing for? Get treatment soon. I want to see your children
before I die.’ For me, this is hard, since I am the infertile
one.’’
The continued pressure forced many couples to avoid
talking and expressing their feelings regarding infertility
and its treatment.
‘‘We did IVF three times without telling any of our
families, because they keep asking about the results,
this irritates me and puts more pressure on us.’’
Adversity of Another Wife
Women expressed their feelings that the husband taking
another wife is inevitable or foreseeable as a solution for their
infertility problem.
‘‘My husband's family pushes him to marry another
woman as soon as possible. I am not happy and I am
sure that this day will come, and my husband will marry
another woman to have a child who will carry his name
and extend his family.’’
Women are also encouraged by their own families to sug-
gest a second wife.
‘‘My brothers are convinced that I should support my
husband to marry another wife to avoid divorce.
Divorce is not acceptable in our society, if I agree to
the marriage I can stay with my husband and I do not
have to go back to my family.’’
The women considered polygamy the husband's right and
a solution to the financial burden of infertility treatment.
‘‘We will try all available treatments; if we fail to have
a baby, I will ask him to marry another woman, because
it's his right to have children and if I do not suggest
a second wife, his mother and sisters will do so.’’
‘‘My husband told me: ‘Shall we waste our money on
IVF? Can I instead save the money to marry another
woman and have children?’ I think this is more useful.’’
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Women were concerned about the sustainability of their
marriage and weighed their available options. They found
that suggesting marriage to a second wife could be the best
solution.
‘‘To keep my husband and gain his trust, I will ask him
to marry another wife, so I can sustain my marriage and
gain the respect of the society and enjoy his children.
His family will respect me too and I will not be consid-
ered a selfish person.’’
Adversity of Changes in the Marital Relationship
Infertile women reported changes in the seriousness of their
marital relationship. The changes were seen in two aspects:
the sexual relationship and the couple's future plans.
‘‘My husband is the one who is infertile. He does not like
to express his feelings, he hides them and shows no
interest in sex. He says: ‘There is no need for making
love’.’’
These statements create more stress for the women and
make them feel that they should ignore their sexual needs.
‘‘There is no sexual relationship between us. Why
should we have sex, we cannot have babies anyway.’’
Women also reported changes in their plans for the fu-
ture. As a couple, they stopped planning for the future and
the women expressed feelings of disappointment at being
unable to follow through with their previous plans and in
some instances, cancelled them.
‘‘When we got married, our dreams and plans were to
have children, build a big house with a room for each
child, save money for their education; it is a problem
now. Who will use the money and the inheritance we
leave behind?’’
‘‘We were living in my husband's family's house, we
then built a big house. Five years have passed and
no children yet. If we had been told that we would
not have a chance to have a baby, we may have stayed
in the same house, and used the money for other
things.’’
DISCUSSION
This study contributes to the body of knowledge on the
adversities of being infertile from the cultural perspective of
Jordanian Muslim women. Although these adversities were
separately reported, they are interrelated and reflect a mixture
of the women's interpretations of their reactions, interactions,
and responses to their infertility problems.
The perception of being incomplete starts when a woman
is unable to conceive naturally and begins infertility treat-
ment. Women's experiences and feelings about being infertile
were evident in their reports of failing to create a family, have
a purpose in life, demonstrate the symbolic changes of
447
ORIGINAL ARTICLE: INFERTILITY
pregnancy, and achieve the goal of marriage in experiencing
a maternal role. Even if the husband is the one who is infertile,
Jordanian women still endure this feeling on behalf of their
husbands. These findings are consistent with other studies
(19–22). Callister (23) raised the issue of gender differences
in responding to infertility and concluded that women
experience more infertility-related concerns such as self-
blame, self esteem, and social avoidance than their male
partners. Furthermore, if the male partner is infertile, the
woman often becomes depressed because she bears his suffer-
ing of being infertile and effects of his personality and social
behaviors (24).
In the Arab and Muslim cultures, a family is not complete
without children, because children are considered a symbol of
continuity of the generations and support the tribal society, in
which larger families are more recognized and hold greater
social status and influence in the country (20, 22). The
reasons for having children, according to Jordanian women,
are to fulfill one's destined role as a woman, create
a family, maintain family lineage, establish future economic
and emotional security, and to provide a safeguard against
divorce (20). Dyer et al. (25), in a qualitative study of South
African Muslim women, report that having a child was the
only wish for these women and they considered having
children the primary function of being a woman. In their
study, one Muslim woman said, ‘‘I cannot be anybody in
the world if I cannot bear children’’ (25, p. 1665).
It is evident from the findings of the study that infertile
couples who remain childless are subject to social pressures
from their families and society. The women felt that the
family's and society's interference intensifies the adversities
of infertility. Women are the ones blamed for infertility. As
a result, women preferred to be isolated to avoid hearing
painful comments from family and friends. Being infertile is
a stigma for which women bear the sole blame. Unfortunately,
all infertility investigations are done on the women first, which
places women under many social, psychological, and marital
pressures (20, 22, 25). These findings support the findings of
Khalaf and Callister (20) who report that infertile Muslim
women are subjected to social pressure to get pregnant as
soon as the first month of marriage. Similar findings are
reported by Fido and Zahid (26) that childlessness subjects
women to social stigmatization and places them at risk for
serious social and emotional consequences.
The most important adversity that emerged in this study,
and one that is not common in Western culture, is the adver-
sity of the husband marrying another woman—polygamy.
Polygamy is supported by the culture and the Islamic religion
as an option for solving the infertility problem (27). The
women participating in this study indicated that allowing
their husbands to have a second wife could be the only solu-
tion for overcoming the social adversities of being infertile.
They reported that they were willing to endure the sociocul-
tural and economic consequences of this solution (27). Infer-
tile women have a persistent feeling that their marriage will
end in divorce if they do not accept the idea of a second
wife. These findings support previous studies (13, 21–28)
that report women's fears of being divorced and/or
abandoned by their husbands. As a result, women felt that
448
their options were limited, forcing them to agree either to
another wife or to a divorce.
Allowing husbands to marry a second wife to have chil-
dren is parallel to the concept of adoption in non-Muslim
countries. Adoption, as perceived in other societies, is forbid-
den in Islam. The alternative term for adoption in Islam is
kafala, which comes from a word that means ‘‘to feed’’ and
is governed by certain rules. The most important rules are
that the adopted child should retain his or her own biological
family name, cannot inherit from his or her adoptive parents,
and members of the adoptive family are not considered blood
relatives and are therefore not ‘‘muhrim’’ to him/her. ‘‘Muh-
rim’’ refers to a specific legal relationship that regulates mar-
riage and other aspects of life (25, 27). As a result of the strict
Islamic rules on adoption and the stigma associated with
divorce, women are left with only one choice, which is that
of a second wife. Women preferred to stay with their
husband to avoid the social stigma of divorce and its
consequences of financial insecurity, lack of family support,
and absence of societal respect (27).
The women in this study reported a change in the marital
relationship as a result of infertility. They reported a change
in their intimate marital relationship because there was no
apparent purpose in having sex, as it would not lead to con-
ception. The change in the relationship was also evident in the
couple's lack of interest in planning their future together and
even in the cancellation of future plans. These findings are
consistent with literature indicating that infertile couples
are faced with the fact that their conscious and unconscious
life-plan may be at risk (9, 29). Exposure of the marital
relationship to negative changes could be related to the
couple's psychological pressures as a result of their inability
to have children in a culture that highly values children and
considers raising children an obligation and the supreme
goal of marriage (27, 30, 31).
In Islam, sexuality is considered part of a person's identity
as a human being. For Muslims, based on an understanding of
the Qur'an (the Muslim holy book) and the Hadith (sayings of
the Prophet Mohamed), sexual relations are confined to mar-
riage between a wife and husband. Within this context, the
role of a healthy sexual relationship is extremely important.
Beyond childbearing, sexual relations assume a prominent
role in the overall well-being of the marriage. Both the
Qur'an and the Hadith allude to the nature of sexual relations
as means of attaining mutual satisfaction, closeness, and
compassion between a wife and husband (32).
In conclusion, infertility is a traumatic life event for
Jordanian women that touches every part of their lives and
is embraced by the societal rules that they are forced to follow.
The adversities described by Jordanian women provide an
insight into how social and cultural meaning of parenthood
influences their experience. These adversities need to be con-
ceptualized within a framework that can be used to empower
and counsel infertile women on how to deal and cope with the
personal, social, and cultural aspects of their experience. It is
crucial for all health care professionals to understand and
interpret the adversities of infertility, so that they are able
to design and implement conductive and supportive programs
for the care of infertile women. Additional evidence-based
VOL. 98 NO. 2 / AUGUST 2012

research is needed to explore the impact of the adversities of
infertility on the well-being of women and their husbands.
Acknowledgments: The researchers extend their appre-
ciation to all the women who participated in this study.
Special thanks to Abeer Atolah, Laila Abdelhadi, and Somaya
Rababah for their assistance in transcribing the data.
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