Experiences of infertility through the lens of Iranian infertile women: A qualitative study
Zahra Behboodi-Moghadam, Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, Touhid Square, Eastern Nosrat Street, 1419733171 Tehran, Iran. Email: firstname.lastname@example.org
Aim: The purpose of this study was to explore and describe the experiences of Iranian infertile women regarding infertility.
Methods: A qualitative design, based on a content analysis approach, was used to reach this study aim. After employing purposive sampling to choose 10 women who were seeking infertility treatment at a referral center in Tehran, Iran, semi-structured interviews were carried out to gather data.
Results: During the data analysis, four main themes emerged including “abuse”, “marital instability”, “social isolation”, and “loss of self- esteem”.
Conclusion: Infertility influences both the psychological and social well-being of women. Improving the knowledge of healthcare professionals especially nurses about the complications of infertility and its related cultural–contextual factors are crucial in order to provide high quality care to infertile women.
Infertility is defined as not conceiving while regularly engaging in unprotected sexual intercourse for 1 year (Devroey, Fauser, & Diedrich, 2009). One of the most important and underappreciated reproductive health problems in developing countries is the high rate of infertility and childlessness (Ombelet, Cooke, Dyer, Serour & Devroey, 2008). In this regard, the World Health Organization (WHO) estimates that 15% of couples worldwide have trouble in conceiving a child (WHO, 2010). Infertility rates vary among different countries (Wiersema et al., 2006). For instance, the prevalence of primary infertility has been reported to be 24.9% among the Iranian population in 2004 (Vahidi, Ardalan, & Mohammad, 2009).
The inability to have a child is frequently considered a personal tragedy affecting the entire family and even the local community. Negative psychosocial consequences of childlessness are common and often severe (Umezulike & Efetie, 2004). In many cultures, womanhood is defined through motherhood, and infertile women usually carry the blame for the couples' inability to conceive. Infertile women are frequently stigmatized, resulting in isolation, neglect, domestic violence, and polygamy (Araoye, 2003; Eftekhar-Ardabily, Behboodi-Moghadam, Salsali, Ramezanzadeh & Nedjat, 2011; Hollos, 2003). In some cultures, traditional or magical treatment is employed for treatment of infertility, but in other cultures, the problem of infertility is solved through adopting a child, remarriage, or even divorce (Even, 2004). For instance, according to Domar, Zuttermeister, and Friedman (1993), half of infertile women changed their sexual relationship and 75% of them experienced mood disorders due to this problem. Furthermore, if couples' efforts to have a child have failed, a detrimental feeling is created (Ryan & Kistner, 1999). In addition, it has been reported that infertile women are deeply worried and feel alone because their situations and securities are affected by the experience of infertility and its treatment as a very stressful event in couples' lives (Widge, 2005).
According to Iranian culture and context, childbearing is highly desirable, where an absence of children with a first wife may lead husbands to take a second wife with or without divorcing the first one (Ramezanzadeh et al., 2004). Moreover, in Iran, family status, especially childbearing, is very important and valuable. Having a child stabilizes the family and increases marital satisfaction (Eftekhar-Ardabily et al., 2011). Infertility in Iran remains a major reproductive health problem and its prevalence is high. According to a recent study conducted in 28 provinces of Iran, lifetime primary infertility was 24.9% in 10,783 women. In addition, approximately one quarter of the Iranian couples experienced primary infertility at some point in their lives (Vahidi, Ardalan & Mohammad, 2009).
It is worth noting that Tehran as Iran's capital has three infertility centers, which infertile women from different parts of the country are referred to seek treatment. The non-governmental Institute of Royan is one of these centers. The Avicenna Infertility Center and Vali-e-Asr Reproductive Health Research Center are academic centers affiliated with Tehran and Shahid Beheshti Universities of Medical Sciences, respectively. Most patients referred to these centers receive in vitro fertilization or intracytoplasmic sperm injection treatments.
It should be noted that central to the delivery of effective infertility care to the patient is understanding the experiences and implications of involuntary childlessness and exploring the context in which these experiences occur (Van Balen & Gerrits, 2001). Although different studies have demonstrated the relationship between physical and psychological suffering and infertility, different aspects of infertility have remained unclear (Cwikel, Gidron, & Sheiner, 2004). Therefore, as there was no qualitative study in Iran to give data on this subject, this study was conducted to explore and describe the experiences of Iranian infertile women regarding infertility.
A qualitative design, based on a content analysis approach, was used to reach this study aim. Qualitative studies are intended to enhance understanding and describe the world of human experience (Myers, 2010). In order to capture the complexities of the psychological and social phenomena, the qualitative methodology is usually utilized. The value of qualitative methodologies in the evaluation of psychosocial implications of infertility has been increasingly recognized (Dyer, Abrahams, Hoffman, & Van der spuy, 2002). Content analysis is a systematic coding and categorizing approach, which can be used to unobtrusively explore a large amount of textual information in order to ascertain the trends and patterns of communication (Gbrich, 2007).
Data gathering and participants
Semi-structured interviews were carried out with 10 women who were seeking infertility treatment at an infertility treatment center for primary infertility (in each case a female factor had been recognized) in Tehran, Iran. All women were interviewed in a private room without the presence of their male partners, whom they all reported to be their husbands. Each interview lasted 45–90 min on average. The foci of the interviews' questions were: (i) the women's experiences of infertility; and (ii) the meaning of infertility from their perspective.
In addition to asking about the educational background of participants, their husbands' educational background was also questioned. The educational status of the interviewees was the same as their husbands, including two with academic degrees, two with secondary education, and six with incomplete secondary education.
The interviews were conducted in Persian by the first author and then translated into English. The second author, as a bilingual translator, supervised the translation and confirmed it. Each interview was recorded and transcribed verbatim and then analyzed concurrently (Elo & Kyngas, 2008; Graneheim & Landman, 2004).
Drawing on work by Graneheim & Landman (2004), the following steps were taken to analyze the collected data:
- 1Transcribing the interviews verbatim and reading through several times to obtain a sense of the whole.
- 2Dividing the text into meaning units that were condensed.
- 3Abstracting the condensed meaning units and labeling with codes.
- 4Sorting codes into sub-categories and categories based on comparisons regarding their similarities and differences.
- 5Formulating themes as the expression of the latent content of the text.
Regarding trustworthiness, credibility was established through member checking, peer checking, and prolonged engagement. Member checking was done by asking the respondents to verify the preliminary findings from the earlier interviews. Two expert supervisors and one other PhD student of nursing conducted peer checking. The researchers independently analyzed the data by identifying and categorizing codes for the subjects' responses to each question, and then the two authors' codes and their latest analysis development as themes were compared. In areas where the two did not agree, definitions were clarified and discussion continued until consensus was reached (Graneheim & Landman, 2004; Rejeh & Vaismoradi, 2010). Prolonged engagement was done by the first author in the research field in order to attract the participants trust and gather in-depth data.
This study is one part of the first author's doctoral dissertation. The Ethics Committee of Tehran University of Medical Sciences approved the study proposal and corroborated its ethical considerations. All participants were informed about the purposes and the methods of this study. The permission to type record the interviews was obtained from the participants. They were informed that participation in the study was voluntary and they could refuse to participate at any time without having any negative impact on the services delivered to them. Those who agreed to participate in the study provided signed written consent.
General characteristics of the participants
The participants' ages ranged 25–45 years (mean, 34; standard deviation [SD] = 5.90). The range of infertility was between 4 and 16 years (mean, 9; SD = 6.62). Two participants had an academic degree, two had secondary education, and six had incomplete secondary education. The educational status of the participants' husbands was similar to the educational status of the participants. The participants' husbands' ages ranged 30–55 years (mean, 41; SD = 6.50).
During the data analysis, four main themes emerged including “abuse”, “marital instability”, “social isolation”, and “lost of self-esteem”. Below, the meaning of each theme is presented by using the participants' direct quotations.
One of the extracted themes from the data was abuse. It consisted of two sub-themes: “psychological abuse” and “physical abuse”. It was found that the feeling followed by infertility, interrupted the mutual understanding between couples in most cases. Psychological violence was one of the common types of violence among women from their husbands and husbands' relatives. A few women experienced physical violence from their husbands due to their infertility.
Psychological abuse. One of the participants said: “My husband sometimes humiliates me due to my infertility and he insults me and my family.”
Another participant said: “I am an educated woman and have a master's degree in arts, but my husband always begins to cry and curse me for my infertility. I feel that my personality is lost in these situations.”
One of the participants expressed that: “my husband always reminds me that if he had married another woman he would already have a child.”
The interactions of infertile couples' relatives were also affected by the condition. When pregnancy was postponed, the relatives began to blame the couples. The blame and pressure of the relatives was actually considered one of significant concerns in the infertile couples' lives. One participant disclosed that: “My husband's family, particularly my mother-in-law and sister-in-law, provoke my husband against me.”
Another informant explained that: “My sister-in-law always tells my husband: ‘divorce your wife and remarry with other woman who can bring you a child.’ ”
In Iran, some couples live with their husband's family. This issue can enable the interference of the husband's family in the private lives of the couples. When a woman is infertile, the family become more involved in the couple's lives and put more pressure on infertile women. One of the participants declared: “I should suffer the humiliations and rebukes of my mother-in-law and cannot do anything.”
Physical abuse. Besides psychological violence, a few women also talked about physical violence. One of the women said: “My husband sometimes beats me. I stay silent because I do not want anybody to be aware of my problems.”
Another participants stated: “My husband is very bad-tempered; he tells me that ‘you were an old girl when I married you. You are infertile, too. It is your right to be beaten.’ Then he beats me and tells me that ‘if you feel uncomfortable here, go to your father's house.’ ”
When couples realized that they could not have a child, difficulties increased and the distance between the couples broadened. Mental pressure caused by the infertility weakened the foundation of the family and even caused divorce. Most of the participants felt that they had lost trust in their husbands and they thought that their husbands did not have any interest in them and might remarry with someone else.
One informant said: “I think that my husband is betraying me. He may marry with another woman to have a child. This issue always worries me.”
Another woman explained that: “My husband comes to the house and says that ‘I want to have a child, and until when should I wait to have a child?’ He is right because if he would have married with another woman, she would have given him a child by now.”
The fear their husbands may remarry with another women was consistent in all of the infertile women, because based on the Islamic doctrine, it is possible for men to remarry.
One of the participants explained: “For a women like me who is infertile and her husband can legally remarry with another woman, it is obvious that living only as a couple becomes boring and causes the couples lose their patience, and their affectionate relationship is interrupted.”
It was believed that having a child could help sustain a generation and stabilize the family. The child could also support them as they aged.
One of the participants explained: “My husband tells me that he will die without having heirs. I feel that it is his right to have a child but I cannot bring him a baby.”
For most participants, infertility had negative social consequences and bothered them. Most of the infertile women asserted that they did not like to participate in social activities and preferred to be alone.
One of them said: “I like to be alone at home and do not like to go anywhere. A woman who does not have a child must stay at home.”
Another woman explained: “I am really tired because people always ask me ‘When are you going to have a kid?’ For this reason, I prefer to stay at home. It is a fact that people talk about their children at parties and a woman like me who suffers from infertility cannot talk about this issue and I find it very painful.”
In some case, relatives had limited contact with the infertile couples. These actions made the infertile couples upset and they felt as though they were in trouble. One of the participants said: “Ever since my relatives understood that I suffered from infertility, they have not invited me to birthday celebrations of their children.”
Loss of self-esteem
One of the objectives of marriage is to have a child in society. It is believed that having a child maintains and preserves the generation. When a woman understands that she is infertile, she loses her self-esteem and feels that she is inadequate. One of informants said: “I would never have married, if I knew that I could not bear a child. Now, I feel useless and think that my works are futile.”
Another woman said: “One of the characteristics of the female is to bear and breastfeed and raise a child. If a woman fails to do this, she is not a perfect woman.”
Another women expressed: “I believe that a woman can reach her final evolution when she can bear a child.”
Some participants in the study asserted that they did not deserve to become mothers and thought that their infertility was a type of punishment from God. One woman mentioned: “ ‘Mother’ is a sacred word and not everybody deserves to be a mother. Perhaps I am one of them.”
Infertile Iranian women might feel that they have failed as wives, and that a woman's life has no meaning without a child. One of the participants said: “I sometimes feel that I am not a woman because I cannot bear a child. I think that I have one thing less than other women.”
This study provides infertile women's perspectives about infertility in the Iranian culture and context. Infertility is a common reproductive health problem in developing countries, which frequently carries negative psychosocial implications. It is well known that infertile women experience mental, physical, and social distresses because of not being able to have a child, and by undergoing fertility treatment (Akizuki & Kai, 2008).
Our findings indicated that negative experiences of infertility in women included “abuse”, “marital instability”, “social isolation”, and “lost of self-esteem”.
The results of a qualitative study conducted in Africa on infertile women showed that loss of self-esteem, anxiety, depression, hopelessness, guilt, marital difficulties, loss of social status, and abuse were consequences of infertility (Dyer, Abrahams, Hoffman, & Van der spuy, 2002; Dyer, Abrahams, Mokoena, Lombard & Van der spuy, 2005). The findings of the present study were in some areas similar to the previous. Infertility is recognized as a major cause of divorce and abandonment (Walraven et al., 2001). In the present study, having a child was seen as the purpose of marriage and the absence of children might cause marital problems. The result of a study on the urban Muslim population in Bangladesh showed that infertile women experienced a loss of purpose in life, instability in their marriage, stigma, and violence (Papreen et al., 2000). In accordance with marriage law in Iran, if it is identified that a man or woman is infertile after marriage, they can be separated from each other. However, the woman rarely separates from her husband due to his infertility. In contrast, when infertility is attributable to the woman, there are more possibilities for divorce and physical and psychological punishment as consequences. Husbands sometimes take a second wife, if the first wife does not desire to separate from her husband.
The present study revealed that physical and psychological violence were exerted on participants because of their infertility. Eftekhar-Ardabily et al. (2011) conducted a study with 400 Iranian women with infertility to determine the prevalence of domestic violence against them. They found that 138 participants (33.8%) experienced psychological violence and 56 of them (14%) had experienced physical violence. Domestic violence is frequently unreported because of shame and blame, fear of reprisal, time-consuming court procedures, and uncertainty in the procedure's outcomes (Yildizhan et al., 2009). Infertile women form a large and vulnerable group with poor reproductive health who deserve attention and care in their own right (Orij, Kuti & Fasubaa, 2002).
In the present study, it was found that couples' relatives limited relations with the infertile couples. Intervention of relatives, especially of the husband's family, negative attitudes towards them, and the behavior of those around them (e.g. family, friends, neighbors) causes psychological problems for infertile couples (Ramezanzadeh et al., 2004).
The findings of the present study showed that infertile women do not like to participate in parties and social gatherings because of fear that their relatives might ask them about their infertility. Isolating behaviors reported during situational crises related to infertility include self-talk and sleep. Interestingly, women have reported the feeling of social isolation more than their male partners (Toscano Sharyl & Montgomery, 2009).
In addition, it was found that infertile women lost their self-esteem due to their infertility. Self-esteem is very important for infertile women because it plays a role in the development of the personality. Without having high self-esteem, infertile women may feel depressed and scared to face unpleasant circumstances (Nuryani & Fakhrurrozz, 2007).
Limitations of this study and suggestions for future studies
This study focused on infertile women and infertility with female factors. Therefore, future studies are recommended to explore the perspectives of infertile women's husbands and address the situation among couples with male factor infertility.
Infertility influences both the psychological and social well-being of women. Improving the knowledge of healthcare professionals especially nurses about the complications of infertility is crucial in order to provide high-quality care to infertile women and prevent negative consequences of this problem including isolation, abuse, loss of self-esteem, and marital instability. Supportive counseling provided by nurses can be a complementary part of treatment in infertile women. Further research is needed in order to devise strategies for reducing the social and psychological complications of infertility and improving patients' quality of life.
This study was supported financially by Tehran University of Medical Sciences. The authors wish to express their sincere gratitude to the study participants without whom this study could not have been conducted.