A qualitative investigation of the experience of participation in Mindfulness‐based Intervention for IVF‐ET (MBII) with Chinese women undergoing first IVF‐ET

Abstract Aim To explore what the women experience during their first IVF‐ET treatment while participating a mindfulness‐based intervention for IVF‐ET (MBII), and how they use it to enhance their infertility‐related quality of life (QoL). Design Qualitative exploratory design. Methods As part of a larger multimethod study, this study shares the description from 38 IVF‐ET women. We conducted semi‐structured interviews and collected daily practice diary. Each interview was conducted one‐on‐one within one week after MBII programme. Data were analysed using inductive thematic analysis. Results Four primary themes described participants’ perceptions of how the programme benefitted IVF‐ET treatment and daily lives: improved infertility‐related QoL, enhanced awareness, increased acceptance and regained control over life. Additionally, enhanced awareness, regained control over life and increased acceptance may be implicated in the effectiveness of MBII on the infertility‐related QoL. Clinicians and nurses working with women undergoing first IVF‐ET have another tool to recommend to the patients.


| INTRODUC TI ON
Infertility is defined by the International Committee for Monitoring Assisted Reproductive Technology (ICMART) and the World Health Organization as the "failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse" (Zegers-Hochschild et al., 2009). It can also be considered as a social and emotional condition described as a low-control stressor in which the couple is challenged with the unfulfilled goal of parenthood (Greil, 1997). Dealing with infertility is frequently perceived as a physically and psychologically challenging experience. Furthermore, infertile women often use in vitro fertilization Embryo Transfer (IVF-ET) treatment to realize their wish to have children. However, an IVF-ET treatment is a painful and stressful process including the daily injections, blood samples, ultra-sound scan, which might bring along some negative effects on a woman's quality of life (QoL) profoundly and enduringly (Kaliarnta, Nihlén-Fahlquist, & Roeser, 2011;Xiaoli et al., 2016). Poor QoL in turn often leads to undesirable consequences such as fewer treatment cycles and a lower mean number of live births (Sejbaek, Hageman, Pinborg, Hougaard, & Schmidt, 2013). Therefore, QoL of infertile women is one of the most important issues to be addressed in infertility counselling (Ferreira, Vicente, Duarte, & Chaves, 2015;Haica, 2013). Fertility quality of life (FertiQoL) is specifically designed for infertile patients to assess their QoL, including two main modules, the Core FertiQoL module and the optional Treatment module (Boivin, Takefman, & Braverman, 2011). Core FertiQoL evaluates the impact of infertility on patients' emotions, physical health, cognition, behaviour, partnership and social aspects. Whereas, Treatment FertiQoL includes environment and tolerability FertiQoL. FertiQoL is condition-specific and aims to measure QoL in all people experiencing fertility problems, and a reliable measure of the impact of infertility on QoL (Aarts et al., 2011).
The FertiQoL tool has been translated into 20 different languages.

| Background
Numerous studies have proven effective psychological interventions could reduce anxiety, depression, uncertainty and other psychological issues, whilst improving fertility-specific QoL and pregnancy rates among infertile women (Chan, Ng, Chan, & Chan, 2006;Domar et al., 2000;Hosaka, Matsubayashi, Sugiyama, Izumi, & Makino, 2002;Kim et al., 2014;Noorbala et al., 2008;Oron et al., 2015). Mindfulness meditation is one example of complementary therapy that has been applied in behavioural medicine (Baer, 2003;Bishop, 2002). Mindfulness is commonly and operationally defined as the quality of consciousness or awareness that arises through intentionally attending to present moment experience in a nonjudgemental an accepting way (Kabat-Zinn, 1994). Mindfulnessbased interventions (MBIs) integrate the essence of traditional mindfulness practice with contemporary psychological practice, in order to improve psychological functions and well-being (Gu, Strauss, Bond, & Cavanagh, 2015). A growing body of robust evidence has demonstrated that MBIs are effective in improving QoL in comparison with control conditions among some populations, such as breast and prostate cancer patients (Witek-Janusek et al., 2008), people with generalized anxiety disorder (Morgan, Graham, Hayes-Skelton, Orsillo, & Roemer, 2014), and recurrently depressed patients (Godfrin & Van Heeringen, 2010). Moreover, MBIs significantly ameliorated the quantitatively measured outcomes among infertile women, such as infertility stress (Peterson & Eifert, 2011), depressive symptoms, internal and external shame, entrapment, defeat and self-efficacy to deal with infertility (Galhardo, Cunha, & Pinto-Gouveia, 2013 However, these quantitative findings did not describe the means by which participants used mindfulness to improve infertility-related QoL or other effects of meditation. There are not first-person descriptions in the literature that describes what the women experience during their first IVF-ET treatment while learning mindfulness meditation, and how they use it to enhance infertility-related QoL. A purely quantitative approach to understanding the effects of mindfulness training is limited, whereas qualitative approaches may add greater insight into psychological mechanisms and characteristics associated with mindfulness than a self-report mindfulness scale alone (Grossman, 2008), and help generate hypotheses for quantitative research methods (Morone, Lynch, Greco, Tindle, & Weiner, 2008).

| Aim
Our objective was to explore what the women experience during their first IVF-ET treatment while participating the MBII programme, and how they use it to enhance their infertility-related QoL.

| Study Context and interventions
The present study was embedded in a non-randomized controlled trial (Li, Long, Liu, He, & Li, 2016) (Segal, Williams, & Teasdale, 2002), Mindfulness-based Childbirth and Parenting (MBCP (Bardacke, 2012) and Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999). Participants met once a week for a 2-2.5hr session for 6 weeks. In addition to in-class mindfulness exercises, the women were encouraged to engage in home mindfulness practices. A total of six groups with 6-8 women per group completed the programme within one year. Sessions were led by the first author who is an experienced clinical psychologist with training in mindfulness-based approaches, and psychological interventions for infertile patients. The techniques used were as follows: body scan, sitting meditation, mindful yoga, walking meditation, loving-kindness meditation, mindfulness anxiety meditation, raisin-mindful eating and mindfulness pain meditation. Meditation practice was supported between sessions through audio-recorded instructions and handouts outlining ways to apply mindfulness skills to daily lives. The study protocol also included homework of daily meditation (Li et al., 2016).

| Sample
Participants were invited to this qualitative study if they: (a) had attended all six sessions; (b) completed a daily diary about their experience completely; (c) had been semi-structured interviewed; and (d) had no language obstacles and agreed to participate in this study.
A sample of 38 women (70.7% response) in the intervention group (N = 58) in our quantitative study was interviewed. Recruitment to the study was based on the inclusion criteria. Of the 58 participants allocated to the MBII group, 48 were interviewed (10 did not attend all of six sessions and/or not filled out a daily diary about their experience completely). The final 38 interviews were selected for analysis based on the information saturation principle. There were no significant differences in demographic, clinical and study variables between 38 participants in this qualitative study and 20 not in the study. Of the 38 participants, the mean age was 30.66 years (between 22-45 years), 42% attended college or had a tertiary education, 32% were unemployed, 59% had a female factor cause for their infertility, the mean infertility duration was 4.7 years (range 1-14) and the mean infertility treatment duration was 2.3 years (range 1-8).

| Data collection
Since diary entries and interview can reveal a rich depth of experience, we conducted semi-structured interviews and collected daily practice diary.
Each semi-structured interview, which took approximately 30 min, was conducted one-on-one within one week after the last session in each group at the reproductive medical centre in Southwest Hospital. Based upon the FertiQoL survey in our quantitative study, seven overarching questions inquiring about the women's experiences in relation to the topics within the FertiQoL guided the interviews (Table 1). The focus was the women's experience of MBII as guided by FertiQoL topics of emotions, mind-body, marital relationships, social relationships, satisfaction with medical quality and treatment tolerability. This interview approach permitted discussion and allowed for data to enter interview that was not directly

TA B L E 1 Interview topics and main questions
sought. All interviews were tape-recorded with consent and transcribed verbatim by the interviewer.
Additionally, the study protocol also covered homework of daily meditation, including practicing mindfulness techniques and completing daily practice diary. After completing mindfulness practice at home each day, participants were required to write down relevant information in the practice log. The headings of the daily practice diary included "Date," "Time," "Place," "Thoughts, emotions and body feelings during the practice," and "The current stage of your IVF-ET treatment." The women's daily practice diaries were collected weekly and returned to the women each week following the transcription. One difficulty with using handwritten diaries can be that entries are sometimes illegible. One investigator transcribed the diaries and another investigator double-checked each transcription and reviewed difficult-to-read handwritten notes. Ultimately only 1% of diary entries were illegible to coders. The participants' quotations were assigned a number that consisted of a "P" (for participant), the participant's randomization number, the page and the line numbers of the quotation within each transcript (e.g. P1/1/1-2 for Participant 1, Pages 1, Lines 1-2).

| Data analysis
The diary entries and interview transcripts were analysed using thematic analysis for its flexibility and potential to generate unanticipated insights (Clarke & Braun, 2013). The analysis followed thematic analytic procedures: becoming familiar with data involving transcription and reflective reading, generating initial codes, searching for themes, reviewing and refining themes, identifying coherent patterns, defining and naming themes and producing the report (Braun & Clarke, 2006). In addition, some themes emerged from the analysis of the interviews, some from diaries, and some from both interviews and diaries.
NVivo qualitative analysis software was used to code transcripts.
A peer-review process took place as a validation strategy to control for author bias in the interpretation of themes (Himelstein, Hastings, Shapiro, & Heery, 2012). A qualified research colleague neutral to this study received full transcripts of all interviews and diaries, and reviewed the codes and themes completely independently of the primary investigator' s participation. This peer reviewer reviewed each code against each meaning unit and quote from the transcripts.
After the primary investigator and neutral colleague met to compare and contrast coded themes, member checking was used to validate the interpretation of the data.

| RE SULTS
Following a thematic analysis of the data, four major themes were identified which captured patients' experiences of mindfulness in relation to their infertility, IVF treatment and daily lives. These included improved infertility-related QoL, enhanced awareness, regained control of lives and increased acceptance (Table 2).

| Improved infertility-related QoL
This over-arching theme described participants' perceptions and evaluations of their infertility-related QoL following the MBII course, including the following six sub-themes. harbor. I am less irritable and impatient than before.

| Improving their infertility-related emotions
(P1/1/12-14) The mindfulness practice offered a way by which participants monitored and controlled their own arousal and could cope with their problems with greater equanimity:

| Improving their infertility-related mindbody state
Twenty-nine women said that these practices helped them "deal with physical pain and other discomforts" (P36/75/13-14), alleviating fatigue and emotion fluctuation during treatment. Mindfulness techniques can directly help them lessen surgery pain such as the hysteroscopic operation-related pain. One participant gave a concrete description of her experience in the interview.

| Improving their relational QoL
Post-MBII programme, 29 participants said that MBII had enhanced closeness with partner, increasing their marital satisfaction.

| Improving their tolerability of IVF-ET treatment
Post-MBII, twenty-eight women reported that they were happy to have these mindful tools to help them to reduce treatment stress and increase treatment tolerability in the diaries: (P20/36/5-8)

| Enhanced awareness
This theme describes that participants increased awareness of their bodies, emotions and thoughts, and could live their moments fully and completely, as well as were able to pay more attention and sustain that attention when stressful invading thoughts, mind wandering and ruminations come to mind. This theme included the following sub-themes.

| Increasing awareness of their bodies, emotions and thoughts
Post-MBII, one of the major changes all 38 participants reported in the interviews and diaries was an increased awareness of their bodies, and how bodily sensations could be related to thinking and emotions.

| Living in the moment more often
Thirty-one participants said that they could live their moments fully and completely. Participants shared how they were better able to enjoy little things in life:

| Greater concentration
Twenty-six participants reported that they were able to pay more attention and sustain that attention when stressful invading thoughts, mind wandering and ruminations come to mind. They also were better aware of and able to manage distractions by bringing their concentration back to their breath. One participant said in the interview.

| Regained control over life
Out of control is a common state for infertile patients. Their lives became so dominated by the infertility experience that they stopped making choices consistent with their life values and goals. During MBII, many participants commented on regaining control of life, which facilitated a transition from helpless and passiveness to senses of perceived control and self-efficacy. This theme included the following sub-themes.

| Both body and mind awakened
Twenty-seven women reported that mindfulness meditation could awaken their body and mind, making them deliberately engaging in nourishing activities rather than immersing into low mood and helplessness:

| Increased acceptance
This theme describes that participants were better able to accommodate ongoing infertility and IVF-related negative thoughts and emotions, having more compassion for themselves and others.

| Destigmatization
Prior to MBII, most participants described negative experiences of being misunderstood, judged and stigmatized by self and others for their infertility and IVF. The programme liberated them from the stigmatizing and self-stigmatizing processes, developing a more positive self-image and social identity. Thus, they learned to accept the reality of infertility and the unpredictability of IVF treatment outcome. One participant said as follows:

| Infertility and IVF-related thoughts and emotions objectified
Twenty-nine participants described a new perspective on their infertility and IVF-related thoughts and feelings, for example "These thoughts and feelings do not represent myself" or "Thoughts are not facts." Thus, infertility and IVF-related thoughts and feelings became more acceptable: It was really important to realize that your thoughts are not necessarily a reflection of who you are. I think that is really helpful. (P16/27/14-16) In addition, 30 participants spoke of increased acceptance to infertility and IVF-related negative thoughts and feelings by realizing that they will pass: You can just go along with the fact that you do feel bad, but it is not going to last forever. It is not the end of the world. I have learned to look at my emotions as a bystander. When I was very anxious for my treatment, I jumped out of myself and looked at me from the view of a bystander. (P20/37/6-7)

| More kind and compassionate to themselves and others
Thirty-three participants said they were less judgemental and more kind and compassionate to themselves coming from acceptance.
Just as one participant wrote as follows: I have more self-compassion. Even if I can not do well, I would love, not punish myself. Accepting myself, the nervous and anxious self! I know that negative emotions will adversely affect fertility, but I can not control them. Please do not criticize myself! Please tolerate, embrace and love myself! (P20/36/20-21) They also reported more tolerance, patience and empathy to others in the interviews and diaries, for example one participant said as follows: It becomes tolerable to queue for seeing the doctor,  The MBII emphasized "letting go" and encouraged a nonjudgemental perspective towards emotions, facilitating emotional acceptance in the infertile women. Mindfulness training provided a way to cultivate emotional balance (Kabat-Zinn, 1990), and may decrease emotional reactivity, facilitating a return to baseline after reactivity (Baer, 2003). Consistent with those assumptions, in this study, participants also commented on the usefulness of MBII for alleviating operation pain and improving quality of sleep. Indeed, one of the first successful clinical applications of mindfulness was in the context of chronic pain (Kabat-Zinn, 2013). The study by Morone et al. (2008) also demonstrated that older adults with chronic pain reported pain reduction and improved quality of sleep resulting from mindfulness meditation. They suggested that by "uncoupling" the physical sensation from the emotional and cognitive experience of pain, the patient is able to reduce pain (Morone et al., 2008).

| D ISCUSS I ON
Additionally, in the present study, most participants described greater emotional closeness with partners and friends, more satisfaction with the medical staff and services, as well as better tolerability for IVF. Social perception processes and felt connection are themselves important outcomes of mindfulness (Brown & Ryan, 2003;Carson, Carson, Gil, & Baucom, 2004;Tipsord, 2009). Previous researches (Barnes, Brown, Krusemark, Campbell, & Rogge, 2007;Burpee, & Langer, 2005;Wachs, & Cordova, 2007) indicated the positive implications mindfulness has for romantic relationship health. The breast cancer patients attending to MBSR also reported improved communication and personal relationships (Hoffman, Ersser, & Hopkinson, 2012). Mindfulness may change the perception of the self such that one begins to view the world F I G U R E 1 Relationship model between the themes of participants' experiences with mindfulness from a broader, more objective perspective rather than a narrowly focused, self-centred perspective (Tipsord, 2009), moving from feelings of separateness to feelings of connection (Kabat-Zinn, 2013 non-judgemental experience of bodily perceptions is thought to enhance connections between the body and the mind, and to promote the acceptance of body symptoms (Mehling et al., 2011). Learning to live in the present moment is seen as a way of letting go of anxiety and re-discovering joy (Finucane & Mercer, 2006). Through mindfulness practice, giving time to be objectively aware of the experience of life as well as living it moment to moment allowed increased acceptance, calm, confidence and ability to cope (Hoffman et al., 2012), all valuable for women facing an uncertain IVF treatment outcomes.
Additionally, through mindfulness practice, participants became more conscious of their internal and experience in the present moment with an attitude of openness and curiosity. Thus, painful thoughts and feelings related to the past (e.g. '"previous abortion"') or to the future (e.g. '"I will never be a mother"') are recognized without trying to suppress or modify them (Galhardo et al., 2013). In addition, other study also found the significant improvements in sustained attention (Chambers, Lo, & Allen, 2008) following mindfulness meditation.
At post-MBII, participants related to infertility and IVF-ET in different ways, accepting them with non-judgement and non-reactivity, and regaining control over life. Regaining control over life is a crucial mechanism that may contribute to the changes in psychological and physical health found in MBSR interventions (Shapiro, Schwartz, & Bonner, 1998). Nearly all of the mindfulness-based treatment programmes include acceptance of thoughts, feelings, urges, or other bodily, cognitive, and emotional phenomena, without trying to change, escape, or avoid them (Baer, 2003). Previous research also showed that breast cancer participants in the MBSR reported accepting things as they were, being less judgemental of themselves and others (Hoffman et al., 2012). In addition, in this study, the process of group members sharing experiences and developing group cohesions may enhance their acceptance of diagnosis and IVF-ET.
As two elements of mindfulness, awareness and non-judgemental acceptance of one's moment-to-moment experience are regarded as potentially effective antidotes against common forms of psychological distress (Hayes & Feldman, 2004;Kabat-Zinn, 2013).
The clinical individuals who practice these skills may experience reductions in a variety of symptom (Baer, 2003;Hofmann, Sawyer, Witt, & Oh, 2010) and improvement in QoL (Van Dam, Sheppard, Forsyth, & Earleywine, 2011). Meanwhile, by directing their attention to the "here and now," practitioners are able to let go of fears regarding the future or ruminations about the past (Shapiro, Astin, Bishop, & Cordova, 2005;van den Hurk et al., 2015). In this way, the women learn to see their habitual reactions to infertility and IVF-ET treatment stressors and to cultivate healthier, more adaptive ways of responding to them. Moreover, intentionally cultivating non-judgemental attention leads to connection, which leads to greater order and health (Shapiro et al., 2006). Lastly, all patients considered the group-interaction valuable, reducing loneliness, ameliorating stigmata, improving communication and empathy, increasing self-efficacy.
There were some limitations in the present study. Firstly, the semi-structured interview guide was based upon the FertiQoL survey. The use of the FertiQol could have limited the responses to the key concepts all the categories emerged from the narrative of the participants. Secondly, it is inherent in the qualitative methodology, that is the findings cannot be generalized beyond this group of participants. This study is one of possibility, rather than probability (Mackenzie, Carlson, Munoz, & Speca, 2007). Thirdly, results only reflect experiences during and immediately after the mindfulness programme and not long-term experiences. Lastly, it is the inherently restrictive format of the diaries themselves. Certain processes of reperception may not have been captured since there were specific guidelines in the diaries (Kerr, Josyula, & Littenberg, 2011).
Therefore, more methods need to be used for data collection in the study in future, such as Focus Group Discussion (FGD).

| CON CLUS ION
Conclusively, this qualitative assessment added to the understanding of the potential benefits of the MBII programme. The MBII has promising potential as an adjunct treatment for infertile women undergoing first IVF-ET. Clinicians and nurses working with women undergoing IVF-ET treatment have another tool to recommend to the patients. Furthermore, in this study, exploring IVF-ET women's lived experience of mindfulness meditation and how they have integrated the practices into their treatment and their lives provides useful information that strongly suggests future directions for research.
Lastly, according to the findings, awareness, control over life and acceptance may be potential mechanisms that lead to improved infertility-related QoL in women following MBII programme. Therefore, that will be useful for isolating important principles of adaptive behavioural and psychological change that is helpful for perfecting the MBII techniques, ultimately improving the treatment effectiveness.

ACK N OWLED G EM ENTS
The authors wish to especially thank all the individuals who responded to our recruitment invitation for their interest in and support of our research. This study was supported by the Chongqing Social Science Planning Project of China granted to J.L.

CO N FLI C T O F I NTE R E S T
The authors declare that they have no conflict of interest.