Yiwei Zhu, The Pennington School, Pennington, New Jersey, USA
Infertility, defined as a couple’s inability to naturally conceive after 12 months of unprotected sex, is a complex problem that extends beyond its biological definition (Jing et al., 2020). Infertile women not only shoulder the burden of an invasive and expensive physical treatment (IVF costs $12,400 per cycle in the USA) but also pressure from spouses, family members, and many other social commentaries, expanding infertility to a social problem (Sternke & Abrahamson, 2015).
Historically, infertility has been associated with stress. As early as 1978, infertility clinics integrated counseling into the treatment process, hoping to address patients’ socio-psychological pressure by increasing treatment complacency and efficiency. Evidence continues to support the benefits of this integrated approach; however, its benefits are not maximized for all infertile patients, especially for those who receive treatment outside of the clinician’s approach (Boivin & Gameiro, 2015).
The World Health Organization (WHO) has classified the socio-psychological consequence of infertility into six levels, as shown below (Figure 1). Given infertility’s global prevalence affecting around 180 million people globally, the socio-psychological issues of infertility are more prevalent and serious than what is commonly known; 1 in 7 couples in the United Kingdom and 1 in 5 couples in Pakistan experience infertility (Inhorn & Patrizio, 2015; Batool & de Visser, 2014). Therefore, it is essential for healthcare professionals and the general public to protect patients from living with fear and instability by understanding the associated socio-psychological pressures.
Figure 1. Levels of consequences of infertility (Hasanpoor-Azghdy et al., 2015).
Infertile women report instability in their marriage, family, and social life as a result of the surrounding stigma. For example, infertile women may be labeled “cold stove” or “dried tree” in Iran (Hasanpoor-Azghdy et al., 2015). In Pakistani culture, infertility is seen as an omen of bad luck (Batool & de Visser, 2014). Multiple studies report that 49-64% of Turkish infertile women experience social stigma as well (Kaya & Oskay, 2020).
Infertile women have developed coping mechanisms against these socio-psychological pressures. Many consciously isolate themselves from social gatherings, and some limit their exposure to the “fertile world” because it exacerbates their perception of infertility as an abnormality to others. For example, some infertile women may avoid meeting pregnant women and children (Hasanpoor-Azghdy et al., 2015). Online forums have connected women of similar experiences to exchange support and create social communities (Sternke & Abrahamson, 2015).
It is more difficult for infertile women in developing countries to alleviate socio-psychological pressure than their counterparts in developed countries. In developing countries, such as Iran and Pakistan, people consider pregnancy as central to a couple’s identity, especially in Islamic countries where motherhood is highly honored. Most developing countries also have a collectivist culture, where people live in extended families. This increases the occurrence of large family gatherings and pressure from relatives to get pregnant. Additionally, a collectivist environment eliminates adoption as an alternative because people consider it a violation of one’s duty to continue inter and intragenerational ties. The enacted stigma of infertility in collectivist developing countries aggravates the felt stigma by infertile women and limits their alternatives outside of treatment. While childlessness is more accepted and respected in developed countries, such as the United States, many infertile women still do not recognize voluntary childlessness as a legitimate option (Hasanpoor-Azghdy et al., 2015).
The fertility quality of life (FertiQoL) questionnaire is a useful tool that quantitatively assesses infertile patients’ subjective perceptions of their lives. On a 5-point Likert scale, FertiQoL contains 34 items that holistically assess patients’ quality of life (Description of FertiQoL, 2017). Given its high reliability score, many studies have already employed FertiQoL as a basis to examine other factors contributing to infertile patients’ quality of life (Boivin et al., 2011). For example, a Chinese study finds higher FertiQoL in people with insurance and unclear etiology of infertility (Jing et al., 2020). A German study finds lower FertiQoL in infertile women from a lower education and income background (Sexty et al., 2018). Socio-demographic factors evidently contribute to inequality in infertile women’s quality of life.
To ensure health equity for all infertile women, their social circles should contribute to creating a healthy environment for them. Healthcare associations should emphasize compassion as an essential quality for professionals in contact with infertile patients (Hasanpoor-Azghdy et al., 2015). Since infertile women come from various backgrounds and experience different socio-psychological pressure, professionals should also be flexible to provide individualized support to patients. Most importantly, healthcare associations should conceptualize infertility as a shared problem between couples, families, and society, whose care and support can alleviate the socio-psychological stress shouldered by infertile women. We should eliminate the stigma surrounding infertility and create a safe and healthy environment for infertile women to make decisions respectful to their own body, family, and life.
References
Batool, S. S., & de Visser, R. O. (2014). Experiences of infertility in British and Pakistani women: A cross-cultural qualitative analysis. Health Care for Women International. http://doi.org/10.1080/07399332.2014.980890
Boivin, J., & Gameiro, S. (2015). Evolution of psychology and counseling in infertility. Fertility and Sterility, 1-4(2), 251-259. http://doi.org/10.1016/j.fertnstert.2015.05.035
Boivin, J., Takefman, J., & Braverman, A. (2011). The fertility quality of life (FertiQoL) tool: Development and general psychometric properties. Human Reproduction, 26(8), 2084-2091. https://doi.org/10.1093/humrep/der171
Description of FertiQoL structure. (2017, November 2). Cardiff University. http://sites.cardiff.ac.uk/fertiqol/description/instrument-description/
Hasanpoor-Azghdy, S. B., Simbar, M., & Vedadhir, A. (2015). The social consequences of infertility among Iranian women: A qualitative study. International Journal of Fertility and Sterility, 8(4), 409-420. https://doi.org/10.22074/ijfs.2015.4181
Inhorn, M. C., & Patrizio, P. (2015). Infertility around the globe: New thinking on gender, reproductive technologies and global movements in the 21st century. Human Reproduction. Update, 21(4), 411-426. https://doi.org/10.1093/humupd/dmv016
Jing, X., Gu, W., Xu, X., Yan, C., Jiao, P., Zhang, L., Li, X., Wang, X., & Wang, W. (2020). Stigma predicting fertility quality of life among Chinese infertile women undergoing in vitro fertilization–embryo transfer. Journal of Psychosomatic Obstetrics & Gynecology. https://doi.org/10.1080/0167482X.2020.1778665
Kaya, Z., & Oskay, U. (2020). Stigma, hopelessness and coping experiences of Turkish women with infertility. Journal of Reproductive and Infant Psychology, 38(5), 485-496. https://doi.org/10.1080/02646838.2019.1650904
Sexty, R. E., Griesinger, G., Kayser, J., Lallinger, M., Rösner, S., Strowitzki, T., Toth, B., & Wischmann, T. (2018). Psychometric characteristics of the FertiQoL questionnaire in a German sample of infertile individuals and couples. Health and Quality of Life Outcomes, 16. https://doi.org/10.1186/s12955-018-1058-9
Sternke, E. A., & Abrahamson, K. (2015). Perceptions of women with infertility on stigma and disability. Sexuality and Disability. https://doi.org/10.1007/s11195-014-9348-6
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