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nfertility is a life crisis with a wide range
of socio-cultural, emotional, physical and communities the childbearing inability is
financial problems (1, 2). More than 80 almost always attributed only to "woman" and
million people worldwide are infertile. that women are often blamed for infertility
Infertility rates vary among different countries, even if the cause of infertility does not relate
less than 5% to over 30% (3). In Iran, a to them (5, 6).
widespread study was conducted in 2005 to While the infertility is not a disease, it and
determine the prevalence of infertility. The its treatment can affect all aspects of people’s
study showed that 24.9% of the couples had lives, which can cause various psychological-
experienced primary infertility during their emotional disorders or consequences
married life (4). including turmoil, frustration, depression,
The evidence demonstrates that most anxiety, hopelessness, guilt, and feelings of
infertile people on the globe live in developing worthlessness in life (7-12). For instance, a
countries and having children in these settings quantitative study in Iran revealed that
is often the only way for women to enhance infertility treatment is amongst the most
their status in the community (5). Despite the stressful factors for the infertile women (13).
Hasanpoor-Azghady et al
132 Iranian Journal of Reproductive Medicine Vol. 12. No. 2. pp: 131-138, February 2014
The psychological consequences of infertility
after two to three times of listening. surviving children were interviewed. Women
Simultaneously in process of data collection, were 21-48 years old. One of them was
the data analysis phase was performed (18). illiterate and the other’s education ranged
Covert or nonreactive observation of actions, from elementary to the Ph.D. degree. In terms
reactions and dialogs of the infertile women in of duration of marriage and duration of
the various parts of the Infertility Center such infertility treatment, they ranged from 3-22
as the reception waiting room, the admission, years and 1-14 years, respectively. Two of
examination and sonography rooms, and them had more than one decade experience
examination room of diagnostic procedures in seeking and doing infertility treatment.
were also recorded. The field notes were Some other relevant characteristics of the
properly recorded and immediately analyzed women are also described in table I. These
in detail. Overall, the data collection and characteristics of participants in study sample
analysis procedures lasted from January to with the maximum sample variation can
October 2012. provide more help to the validity and
As aforementioned, the phase of data transferability of findings to other similar
analysis was performed using the groups and settings (18).
conventional content analysis as a type of As infertility and its treatment process can
QCA. In this method, the systematic both cause psychological-emotional
classification processes are used to identify consequences in the participants, these
codes and themes within the content of the varieties of consequences were grouped to
study (19). In this QCA, codes were extracted psychological-emotional consequences of the
from the meaningful units of the participants’ infertility and psychological-emotional
descriptions and classified according to consequences of treatment process in this
similarities or dissimilarities, based on which study. In this view, main concepts obtained
the relevant themes were identified. For the from the data were categorized into four main
rigor the data collection process the four themes and their sub-categories (Table II).
criterions of Lincoln and Guba was used: This scheme of separation in some instances
including credibility, dependability, led to sub-categories as psychosocial turmoil
confirmability and transferability (18). In order as seen in two themes; one related to the
to different methods were used, such as the infertility and the other related to its treatment
diversity of participants, engagement with the process.
participants and the research setting,
clarifying the participants on the objectives of Cognitive reactions of infertility
the study, data analysis of transcriptions This theme includes two sub-categories:
immediately after the interview and feedback mental engagement and psychological
for the next interview. The data were verified, turmoil. According to participants'
corrected and revised using the voices and experiences, the topics such as possibility of
reactions of the participants and observers. remarriage of spouse, curiosity of the
Research process was done from the significant others about the infertility of the
beginning to the end under the supervision of participant, and regret feelings the husband’s
supervisors and peer debriefing. Some in witnessing fertile couples were the causes
auditory files, typed and coded interviews and of mental engagement of the participants. In
all initial codes and categories were evaluated addition, some pregnant women hiding their
by peer debriefing. Some typed and coded pregnancy from the participants also caused
interviews were examined by member check. them to become mentally engaged. Also the
All collected and recorded data have been participants who had hidden their infertility
saved as computer files for reviewing and always had mental engagement that what
peer debriefing if needed. To examine the would happen if the issue was disclosed. As
transferability of the study, data were made one of the participants stated, “I am constantly
available to the several of infertile women who thinking if people are aware of my problem
did not participate in the study, asking them to what will happen” (Participant17).
compare the results with their own experience Moreover, sometimes participants were
(18). upset by hearing about pregnancy or childbirth
of a woman, talking of the husband and the
Results kids and humiliating behaviors of some
people. One of the participants expressed her
A total of 25 women with a history of feelings in this choked voice, “some pregnant
primary and secondary infertility with no women or those recently given birth touch my
Iranian Journal of Reproductive Medicine Vol. 12. No. 2. pp: 131-138, February 2014 133
Hasanpoor-Azghady et al
head with their right hand, which really upsets Turning age 30 as a restriction on fertility
me’’ (p4). and the social pressure around on the
husband of participants due to fertility
Cognitive reactions to the therapy process problems were their main concern in the
This theme includes the sub-categories as family. As narrated by one of the participants
follows: psychological turmoil; being difficult to “I cannot stand the way people look at me and
control in some situations; the reduced self- my husband. Needless to say that I fear my
esteem and feelings of failure. Many husband gets disrupted again. His feelings are
participants were upset following the events really essential to me’’ (p14). Another
that were generated in the treatment process participant said, “Since I got married very late.
such as hearing negative pregnancy test I'm concerned about not to respond to
especially when they spend a lot of money, treatment’’ (p25).
consuming drugs and passing treatment steps There are feelings of loneliness and guilt
that in some procedures were invasive. The from items that were reported by participants.
needs for surgery on the genitals or using a As a participant expressed, “My home is silent
surrogacy or oocyte donation caused from morning to night so that sometimes I am
tremendous shock to them. talking to myself in the fear of not becoming
As one of the participants said, “When the dumb” (p4). The participants who get
doctor told me that I have to use a donated emotional support from their families,
ovum, I was shocked’’ (p13). In such especially from their husbands, have a feeling
conditions, participants were losing control of guilt not being able to make their husband
over their emotions and actions. A participant the father of a child. As one of participants
declared her feeling in this way: “I was so stated, ’’I have tested my husband several
distracted while driving home that I had an times he is so gentle and never blames me as
accident and actually cried. I was frustrated an infertile woman. This constantly causes my
and asked God “I’m really tried. What should I guilt consciousness as I think I am the source
do?” (p6). of his misery in this regard’’ (p16).
Frequent failures in remedying infertility in Most participants, however, experienced
some participants and learning about the sadness one way or the other due to
failure of other treatments at the Infertility expressed worries by the family members, the
Center which some participants experienced bitter reactions of their community or being
reduced their self-esteems. Women who blamed by their husbands for the infertility.
become pregnant, which afterwards end in These issues were generally related to the
miscarriage, experience a sense of failure. As duration of infertility and the longer the
some of women said with tearful eyes, “So participants experienced infertility, the more
much medicine and treatment substantially they became depressed. As one of the
reduced my self-confidence’’ (p12). Another participants stated, “12 years of infertility is a
participant stated “I was sure the fetus will life time. Now I am completely depressed. I
stay and that I am becoming mother from the can bear no more’’ (p20). Another sub-theme
moment they implanted it, but finally I lost my was the theme of regret created in participants
child’’ (p16). when they see a family embracing a child,
conduct and observe pregnant women, small
Emotional- affective reactions of infertility children and babies especially while they are
The third theme consists of the sub- being breastfed, or call “Mommy”. A
categories of fear, anxiety and worry; participant expressed her feelings in these
loneliness and guilt; grief and depression and words, “When I see a pregnant woman, I say
regret. According to the results, fear and to myself: God, when will I be wearing
anxiety from disclosure of infertility from pregnant women’s clothes?’’ (p23).
persistence of absolute infertility happens for
many participants. As one of the participants Emotional-affective reactions to the
expressed, “I fear that I can never have a child therapy process
particularly that my husband eternally loves This theme includes four sub-categories of
and supports me. I constantly ask God, don’t fear, anxiety and worry; fatigue and
disappoint me in this way’’ (p19). Another helplessness; grief and depression; and
participant said, “Although I told my husband hopelessness. Fear of taking a pregnancy test
before marriage that I have problems to result and fear of telling the husband the
become pregnant, but I'm afraid what happens negative result in some participants, anxiety
in the future’’ (p7). about how the therapy process proceeds and
134 Iranian Journal of Reproductive Medicine Vol. 12. No. 2. pp: 131-138, February 2014
The psychological consequences of infertility
concerns about the result of treatment are field of research indicated that the participants
some of issues experienced by the were frequently surprised and concerned
participants. As a participant said, “I am about costs of the treatments.
worried if I do all of these and results turn out Some participants were asking the medical
to be negative, what I should do’’ (p10). staff about where they could get loan or
The frequent use of hormonal treatments reduce costs, to which unfortunately they did
and non-medical interventions such as IUI and not receive an encouraging answers. Some
IVF and repeated failures was frustrating for participants for providing costs stopped
some of the participants. Frequent and long treatment. As one of the participants
trips from participants’ hometowns to the expressed, if the system is performed
infertility center as well as unexpected length successfully I can apply IVF. I cannot do it as
of treatment cycles made some of them it is not affordable; I have nobody and no
exhausted and hopeless, as one of the source to seek help’’ (p8). When participants
participants stated, “I am really tired after so with plenty of difficulties were able to provide
many years, really exhausted’’( p22). for the cost of the treatment and started the
Another participant said, “Sometimes I feel process of treatment with hopes or dreams for
really frustrated, I like to commit suicide’’ (p5). the fertility, the prospects of defeat would
Experience of such boring conditions has become intolerable to them. Extreme
caused many participants to become grief- hopelessness captured them when the fertility
stricken, and depressed. A participant test after the treatment was positive but after a
narrated her experience in this way, few weeks the pregnancy was interrupted.
“Whenever I see that my test result is One of the women expressed her feeling by
negative, I say to myself ‘I wish I could these words, “When a lot of enthusiasm
become pregnant’. My heart is full of sorrow results in failure, you become extremely
and pain’’ (p10). The observations done in the hopeless and disenchanted” (p3).
Iranian Journal of Reproductive Medicine Vol. 12. No. 2. pp: 131-138, February 2014 135
Hasanpoor-Azghady et al
Table II. The main themes and sub- themes in this study
The main themes Sub-themes
Cognitive reactions of infertility Mental engagement; psychological turmoil
Cognitive reactions to therapy process Psychological turmoil; being difficult to control in some situations; reduced self-esteem;
feelings of failure
Emotional-affective reactions of infertility Fear, anxiety and worry; loneliness and guilt; grief and depression; regret
Emotional-affective reactions to therapy process Fear, anxiety and worry; fatigue and helplessness; grief and depression; hopelessness
136 Iranian Journal of Reproductive Medicine Vol. 12. No. 2. pp: 131-138, February 2014
The psychological consequences of infertility
such treatments with psychosocial turmoil. In psychological distress is the social pressure
a cross-sectional study of 585 couples who by community members. According to the
had been reported in women’s using hormone results, while the medical discourse of
injections, 53% reported discomfort on the infertility is dominant, its mental-emotional,
treatment that failed, and 44% expressed socio-cultural and political aspects are still
anxiety while being treated. Two of the most neglected in Iran.
common negative feelings were hopelessness As infertility is more common among
and impatience. 49% of respondents reported people from the low social classes who do not
they felt uncomfortable when they were have the ability to afford psychological
around pregnant women or couples with counseling costs and social determinants play
children (26). Our participants also had an important role in creating the psychological
experienced grief and hopelessness following consequences of infertility, this study suggests
repeated failures, anxiety during the treatment that having professional trained social workers
process and unclear result and the feeling of as complementary medical interventions in the
regret seeing pregnant women like some infertility clinics is central to manage the issue
earlier studies in the literature (12, 20). of infertility in all aspects. This profession
The stresses stem from the unaffordability assistance not only meets the needs of
of the infertility treatment costs, especially infertile people but also the needs of the social
among people with no health insurance system in which infertile people are living. In
coverage were observed in this study. In this view, social workers can support the
addition, the infertility treatments are not still rights and needs of infertile people as a
covered fully by the health insurance systems means to development planning by policy-
of the country, and this is why most Iranian makers so that the infertility can be looked
participants were concerned about how to upon as a biopsychic social phenomenon.
cover the costs. In this view, as Verhaak et al
observed, there is reduction of depression and Research limitations
anxiety among women who had IVF even if The researchers recognize the necessity of
they would lose a pregnancy chance (2). selecting their case studies from women with
As Dyer observed, despite of the different socio-economic levels since it is an
differences in socio-cultural backgrounds in influential parameter on the complications
developing countries, many studies have following the treatment. However, since most
shown that infertility consequences are often advantaged infertile individuals use private
surprisingly similar there, but there is a infertility centers, and these centers denied
significant difference between the experience researchers’ request for interviews, the study
of infertility in developing and developed does not include women from this group. The
countries (2, 10). Infertility in developing researchers tried to partially overcome this
countries means a patient's body and a limitation with adding some cases to the study
human identity has not completed that have by picking women who use public clinics but
directive consequence of the social and they are from higher income families.
psychological, because fertility is so central to The recruited participants included women
women’s power (3). In developed societies who had volunteered to participate in the
voluntary childlessness is viewed as a more study that, compared with non-volunteered
viable and legitimate option and women infertile women, may have less psychological
without children are often presumed to be consequences.
voluntarily childfree in cultures in which there
is no concept of voluntary childfree status, it is Acknowledgments
impossible to hide infertility (2). Distress of
infertility, therefore, is likely to be greater in We would like to express our heartfelt
developing countries (27). gratitude to all infertile women who
participated in the study for generously giving
Conclusion their time and energy in helping to complete
the qualitative interviews. We also thank
This study showed that the infertility and its officials of Vali-e-Asr Reproductive Health
treatment process for Iranian infertile women Research Centre and members of the School
is a source of psychological suffering with of Nursing and Midwifery at Shahid Beheshti
devastating effects on psychological well- University of Medical Sciences (SBUMS) for
being of infertile couples. The results also their sincere cooperation in this study. The
showed that one of the major causes of authors verify that this project has been
Iranian Journal of Reproductive Medicine Vol. 12. No. 2. pp: 131-138, February 2014 137
Hasanpoor-Azghady et al
supported financially by Shahid Beheshti fertile and infertile women. J Reprod Infertil 2009; 9:
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Conflict of interest Reprod 1998; 13: 1733-1736.
15. Lechner L, Bolman C, van Dalen A. Definite
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