Help‐seeking patterns among subfecund women

Defining infertility: a qualitative interview study of patients and physicians

PURPOSE

To investigate if infertility patients and physicians apply a traditional biomedical model of disease in their conceptualisation of infertility, examine any contradictions and conflicts in conceptualisations, and examine areas of concordance and discordance between physicians and patients.

METHODS

Semi-structured interviews were conducted with 20 infertility patients and 18 infertility physicians between September 2010 and April 2012. Interviews were analysed qualitatively to determine physician and patient conceptualisations of infertility, reactions to the definition of infertility as a disease, and potential benefits and concerns related to application of a disease label to the condition.

RESULTS

Most physicians (n = 14/18) and a minority of patients (n = 6/20) were supportive of defining infertility as a disease. Many of the patients who agreed with classifying infertility as a disease expressed that they had not personally defined it as such previously. Physicians (n = 14) and patients (n = 13) described potential benefits of a disease label, including increases in research funding, insurance coverage, and social acceptability. Some patients (n = 10) described potential stigma as a negative consequence. When describing appraisals of infertility, both physicians (n = 7) and patients (n = 8) invoked religious/spiritual concepts. The potential for religious/spiritual appraisal to contribute to stigmatising or de-stigmatising infertility was discussed.

CONCLUSION

Our findings contradict the assumption that infertility physicians and patients are fully supportive of defining infertility as a disease. While potential benefits of the disease label were recognised by both groups, caution against potential for stigmatisation and unsolicited invocation of religion/spirituality suggest a more holistic model may be appropriate.

PREVALENCE AND RISK FACTORS OF INFERTILITY IN UKRAINE: RESULTS A MULTICENTER STUDY (2019-2021)

OBJECTIVE

The aim: To assess the current prevalence and identify the risk factors for infertility among couples of reproductive age in Ukraine.

PATIENTS AND METHODS

Materials and methods: We conducted a retrospective multicentre cohort study was based on reproductive health surveillance data among married populations from January 1st, 2019 to December 31st, 2021 in Ukraine. Definitions of infertility were used from the WHO.

RESULTS

Results: Among all the 6,885 participants in this study, the prevalence of infertility was 25.4%. The prevalence of primary infertility was 5.8%, and the prevalence of secondary infertility was 19.6%. The levels of infertility in the regions of Ukraine had significant differences. It was found that among those women who had primary infertility, more were from rural than urban, while for secondary infertility women the situation was reversed. Infertility was associated with age, history of gynecological surgery, decreased ovarian reserve, age of marriage, long-term air-conditioning environment, and history of endometriosis. There were differences among factors associated with infertility, primary infertility and secondary infertility. The factors associated with primary infertility were age of marriage, age of first sexual intercourse, long-term air-conditioning environment, decreased ovarian reserve and age. A factors associated with secondary infertility were history of gynecological surgery and decreased ovarian reserve.

CONCLUSION

Conclusions: The results of this study revealed high level the prevalence rate of infertility among couples of reproductive age in Ukraine is high. This applies to both primary and secondary infertility of married women. The most women who had experienced infertility have not sought medical or professional help for the problem.

Lavender Aromatherapy to Reduce Anxiety During Intrauterine Insemination: A Randomized Controlled Trial

Background

Infertility is a global public health issue. Therapies such as intrauterine insemination (IUI) are effective but may be associated with considerable anxiety. Preliminary data suggest that decreasing this anxiety might lead to improved outcomes.

Objective

To determine whether lavender aromatherapy (LA) reduces anxiety during an IUI procedure.

Methods

A randomized controlled trial of women undergoing IUI at a hospital-based fertility clinic. The intervention and comparison were the use of LA vs water. Measurements were the change in anxiety level during an IUI procedure, with secondary assessment of pain scores, patient satisfaction, and pregnancy rates.

Results

In total, 67 women were screened, and 62 women randomly assigned to either placebo (n = 31) or LA (n = 31). No differences were observed in baseline demographic characteristics or visual analog scores for anxiety before IUI (mean [95% CI], 33.9 [25.2 to 45.6] mm vs 41.0 [33.0 to 49.0] mm) in the LA and placebo groups. However, a statistically significant change in anxiety was observed after LA inhalation during the procedure (mean [95% CI], −11.2 [−19.1 to −3.2]) compared with placebo (mean [95% CI], 1.3 [−5.6 to 8.2]; P = .02). No significant difference was observed in pain during IUI in the LA group vs placebo group. Patient satisfaction was high, with 93% of respondents in the LA group satisfied with the aromatherapy during their procedure. Additionally, 76% of participants who received placebo reported that they would prefer to use LA during their IUI. No statistically significant difference was detected in pregnancy rates between the 2 groups: 19.4% with LA vs 9.7% with placebo (P = .47).

Conclusion

LA reduced anxiety and was preferred by women during IUI fertility treatments.

Fertility health information seeking among sexual minority women

OBJECTIVE

To qualitatively explore and describe fertility information-seeking experiences of sexual minority women (SMW) couples using assisted reproduction.

DESIGN

Qualitative thematic analysis of 30 semistructured, in-depth individual and dyadic interviews with SMW couples.

SETTING

Video conferencing.

PATIENT(S)

Twenty self-identified lesbian, bisexual, and queer women comprising 10 same-sex cisfemale couples (10 gestational and 10 nongestational partners) using assisted reproduction technology in the United States.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

We describe how SMW came to learn about ways to achieve pregnancy through information seeking, acquisition, appraisal, and use.

RESULT(S)

Analysis revealed three primary themes. First, uncertainty and information scarcity: SMW have basic knowledge about how to conceive but uncertainty persists due to information scarcity regarding how same-sex couples navigate assisted reproduction. Second, women attempt to collect fragmented information from disparate sources. The participants discussed a mixture of formal and informal, online, textual (books), and in-person seeking, finding, and synthesizing information that ranged from reliable to unreliable and from accurate to inaccurate. Finally, persistent heteronormative communication focused on the needs and conditions of male-female couples who experienced subfertility or infertility, rather than barriers related to social constraints and the absence of gametes that SMW sought to overcome.

CONCLUSION(S)

These findings support and extend existing evidence that has focused primarily on online fertility information seeking. Our findings suggest that shifts in fundamental assumptions about who seeks assisted reproductive support and why, together with improvements in fertility-related health communication, may result in more inclusive care for this population.

Factors associated with medical help-seeking for infertility in developed countries: A narrative review of recent literature

The reasons why people decide for or against seeking medical help for infertility are still far from clear. With advances in reproductive medicine, use of medically-assisted reproduction has increased over the last three decades. Over the same period, an appreciable amount of quantitative studies on the determinants of medical help-seeking for infertility has accumulated. However, to our knowledge this narrative review is the first to summarize and evaluate findings from these studies. This review includes 39 studies carried out in 11 countries, covering the period 1990-2019. We have identified five categories of determinants of help-seeking: socio-demographic variables, socio-economic factors, reproductive history, attitudes, and psychological factors. Each category consists of several variables. Considerable knowledge has accumulated on socio-economic variables, indicating that there is social inequality in access to treatments in several countries. Less is known about marital status, attitudes and psychological factors. Findings on the latter two mostly derive from two US surveys. Overall, the body of research appears heterogeneous and fragmented. Studies differ in central aspects of study design (definitions of the analysis sample and of help-seeking, type of analysis (bivariate or multivariate), set of variables included in multivariate studies) making comparisons of findings difficult. Low comparability is reinforced by country differences in the provision of treatment, legislation on access and treatment coverage. The majority of papers lack a theoretical foundation or reference to any theory. Using a theoretical framework to guide empirical research could help to overcome the problems described above. Single-country studies should include information on legal and cultural context. More studies from countries other than the US are needed as well as multi-country studies in order to develop a systematic understanding of how macro-level structures relate to decisions about medical help-seeking. This review should assist future researchers in their attempt to conduct studies on help-seeking for infertility.

On estimating the prevalence of use of medically assisted reproduction in developed countries: a critical review of recent literature

BACKGROUND

Existing reviews on the prevalence of use of medically assisted reproduction (MAR) are relatively old and include mainly studies from the 1980s and 1990s. Since then, MAR has developed at a rapid pace, public awareness and acceptance of medical solutions to infertility problems has increased, and, consequently, the use of MAR has risen in developed countries.

OBJECTIVE AND RATIONALE

This study provides a comprehensive overview of the state of research on the prevalence of MAR use in women and men, as well as a critique of methodology used in studies of the use of MAR, and suggestions for moving forward.

SEARCH METHODS

Articles were located via the databases Academic Search Complete, Biomed Central, FirstSearch, Google Scholar, Medline, Health and Medical Collection, Medline and Social Science Citation Index using the key words 'infertile', 'infertility', 'subfecund', 'subfecundity', 'treatment', 'help-seeking', 'service use', 'service utilization', 'ART use' and 'MAR use' separately and in various combinations. The focus was on studies from developed countries, published between 1990 and 2018, in English, German or French.

OUTCOMES

In this article, we have reviewed 39 studies covering 13 countries or regions; approximately half of these covered the USA. Ten studies were published in the 1990s, 10 in the 2000s and 19 since 2010. Studies report different types of prevalence rates such as lifetime and current prevalence rates of MAR use. Prevalence rates are based on very different denominators: women who tried to become pregnant for at least 12 months without success, women who experienced at least 12 months of unprotected intercourse without success, women of reproductive age from the general population or women with a life birth. There are few studies that report help-seeking rates for men or make direct comparisons between genders. Knowledge on medical help-seeking across different stages, such as seeing a doctor, undergoing tests, having operations to restore fertility or ART, has started to accumulate in recent years. There are conceptual reasons for being cautious about drawing conclusions about gender, regional, country level and differences over time in help-seeking rates.

LIMITATIONS REASONS FOR CAUTION

In a narrative review, the risk of bias in the interpretation of findings cannot be completely eliminated. The literature search was limited to languages the authors speak: English, French and German.

WIDER IMPLICATIONS

In line with earlier reviews, we found that studies on help-seeking are not comparable across time and space, preventing researchers and healthcare providers from understanding the relation between social change, social policy, social structure and help-seeking for infertility. The discussion in this article should assist future researchers in designing better studies on the prevalence of MAR use. We provide suggestions for producing better estimates of the prevalence of MAR use. More cross-country and cross-gender comparisons are needed. Studies that treat help-seeking as a continuum and report on different stages are preferable compared to choosing arbitrary cutoff points, as is common practice in the studies reviewed.

STUDY FUNDING/COMPETING INTERESTS

None.

Information needs of people seeking fertility services in Canada: a mixed methods analysis

BACKGROUND

Infertility is a challenging experience associated with high levels of psychological distress. Many people seeking fertility services use the internet to obtain information about their conditions and treatments.

OBJECTIVES

This mixed-methods study aimed to describe the information-seeking experience of people seeking fertility services with respect to the fulfillment of their individually defined information needs and explore relationships between the fulfillment of information needs and psychological outcomes.

METHODS

One hundred and four participants completed a survey with close-ended and open-ended questions about their experience using an informational web-based application (app) called 'Infotility' and about their mental well-being before and after using the app. The questionnaires administered were the The Mobile Application Rating Scale (uMARS), the Fertility Quality of Life questionnaire (FertiQol), the Patient Empowerment Questionnaire (PEQ) and the General Anxiety Disorder 7-item Scale (GAD-7). Eleven participants completed in-depth qualitative interviews about their experience using the app. A thematic analysis was used to interpret qualitative results and quantitization was used to dichotomize participants into those with met information needs versus those with unmet information needs. Google Analytics was used to compare participants' reported experience with their actual use of the app.

RESULTS

The results of this study show that there is variability in the amount of information that people seeking fertility services wish to receive. Participants whose information needs were met reported improved psychological outcomes after using the app, while those with unmet needs showed no change in their psychological outcomes.

CONCLUSIONS

Our results suggest that fulfilling information needs was associated with improved psychological outcomes in people seeking fertility services. Our results also suggest that individual differences in information needs should be considered when developing health educational materials.

Does Self-Identifying as Having a Health Problem Precede Medical Contact? The Case of Infertility

Studies of medical help-seeking presume that self-identifying as having a health problem precedes medical contact, but this ordering of the identity-behavior relationship has not been systematically examined. We used longitudinal data from the National Survey of Fertility Barriers (2004 to 2010) on 412 women with infertility to document the temporal relationship between self-identifying as having a fertility problem and making medical contact. The symbolic interactionist perspective suggests that infertility will be perceived as identity disruption and that in response women will align self-identity and medical behavior over time. Cross-tabulation analysis indicated that more women do self-identify as having a fertility problem first (24 percent) as opposed to making medical contact first (5.5 percent). There was also a tendency toward aligning self-identification and behavior over time. Latent class analyses revealed six patterns: 1) consistently involved, 2) early consulters, 3) consistently uninvolved, 4) consistent perceivers, 5) medical dropouts, and 6) early perceivers. Strong fertility intent and primary infertility, two identity-relevant characteristics, had the strongest associations with latent class membership. The relationship between self-identification and medical help-seeking is thus dynamic and complex.

An internet-based mind/body intervention to mitigate distress in women experiencing infertility: A randomized pilot trial

OBJECTIVE

To determine if an internet-based mind/body program would lead to participants experiencing infertility (1) being willing to be recruited and randomized and (2) accepting and being ready to engage in a fertility-specific intervention. Secondary exploratory goals were to examine reduced distress over the course of the intervention and increased likelihood to conceive.

METHODS

This was a pilot randomized controlled feasibility trial with a between-groups, repeated measure design. Seventy-one women self-identified as nulliparous and meeting criteria for infertility. Participants were randomized to the internet-based version of the Mind/Body Program for Fertility or wait-list control group and asked to complete pre-, mid- and post-assessments. Primary outcomes include retention rates, number of modules completed, and satisfaction with intervention. Secondary exploratory outcomes sought to provide preliminary data on the impact of the program on distress (anxiety and depression) and self-reported pregnancy rates relative to a quasi-control group.

RESULTS

The retention, adherence, and satisfaction rates were comparable to those reported in other internet-based RCTs. Although time between pre- and post-assessment differed between groups, using intent-to-treat analyses, women in the intervention group (relative to the wait-list group) had significant reduction in distress (anxiety, p = .003; depression, p = .007; stress, p = .041 fertility-social, p = .018; fertility-sexual, p = .006), estimated as medium-to-large effect sizes (ds = 0.45 to 0.86). The odds of becoming pregnant was 4.47 times higher for the intervention group participants as compared to the wait-list group, OR 95% CI [1.56, 12.85], p = .005 and occurred earlier. The findings suggest that the research design and program specific to this population are feasible and acceptable. Replication efforts with an active control group are needed to verify distress reduction and conception promotion findings.

Patient identified factors influencing decisions to seek fertility care: adaptation of a wellness model

Objective: To adapt a fertility care wellness model.Background: Despite availability of a range of diagnostic and therapeutic services for infertility, many do not seek care or discontinue care prior to achieving a live birth. Wellness models can inform research on patient decisions to seek and continue fertility care, as many barriers and drivers are represented within the dimensions of wellness.Methods: A mixed-methods online survey was completed by 135 people of reproductive age who experienced infertility in the USA. Outcomes included drivers and barriers to seeking or continuing fertility care. Identified factors were compared by treatment history using chi-square and Fisher's exact tests. Themes and patterns were identified within 174 responses to 6 open-response items through conventional content analysis.Results: Thematic analysis revealed practical (environmental, financial, and physical) and affective (emotional, social and spiritual) dimensions of wellness in decisions to seek care (67%), with affective rationales more prominent in decisions to return for care (78%).Conclusion: Decisions to seek fertility care and return after failed treatment integrate practical and affective rationales from financial, physical, environmental, emotional, social and spiritual wellness dimensions. Drivers and barriers within these dimensions should be considered to encourage care seeking and improve patient retention.

Degrees of Medicalization: The Case of Infertility Health-Seeking

We examine responses to infertility among a sample of 2,361 women with infertility from the National Survey of Fertility Barriers. Latent class analysis uncovered seven latent classes of behavioral response which can be arranged in a rough continuum from least medicalized to most medicalized response. We then aggregated these seven categories into three schemas representing various degrees of medicalization. Women in each class combine treatment-seeking, knowledge-seeking, socio-emotional support seeking, and non-medical solution-seeking strategies. Even women pursuing the greatest degree of medicalization in their health-seeking (e.g., fertility treatments, assisted reproduction) made use of a variety of medical and non-medical health-seeking resources.

Gatekeepers for infertility treatment? Views of ART providers concerning referrals by non-ART providers

Many patients who might benefit from treatment using assisted reproductive technology (ART) do not receive it, raising critical questions of why, and how best to overcome existing barriers. In-depth interviews of approximately 1 h each were conducted with 27 ART providers (17 physicians and 10 other healthcare providers). These interviewees suggest that non-ART providers may serve as gatekeepers in a complex system, involving not only individual-level, but also dyadic and institutional, processes and factors related to provider-patient relationships. Differences emerge concerning 'who' refers patients for ART (e.g. what types of provider), 'how' (amount, type and specificity of information offered), 'when' (delayed or not) and 'why or why not', and how patients respond to referrals, once made. At least seven types of clinician (general practitioners, obstetricians/gynaecologists, paediatricians, geneticists, psychologists and oncologists) may refer patients. Barriers to referral include indistinct boundaries between specialties and provider discomfort discussing reproduction and sex. These data, the first to explore dynamic factors and processes related to provider-patient relationships and interactions in referrals of patients for ART, suggest several key issues (e.g. non-ART providers' roles as gatekeepers), and implications for future education, practice, guidelines and research, highlighting a research agenda, and the need for targeted education for different groups of clinicians.

Catch 22? Disclosing assisted conception treatment at work

Purpose

The purpose of this paper is to explore factors influencing decision making about disclosure of assisted reproductive technology (ART) use in the workplace.

Design/methodology/approach

A qualitative study design was used. In total, 31 women and 6 men who were using or had recently used ART were recruited from British fertility networks and interviewed. Data were transcribed verbatim and thematically analysed.

Findings

Two main strands were identified each encompassing two themes: “Concerns about disclosure” covered the very personal nature of disclosing ART treatment and also career concerns and “Motives for disclosure” covered feeling which was necessary to disclose and also the influence of workplace relationships.

Research limitations/implications

The relatively small, self-selected sample of participants was recruited from fertility support networks, and lacked some diversity.

Practical implications

Clarity about entitlements to workplace support and formal protection against discrimination, along with management training and awareness raising about ART treatment is needed to help normalise requests for support and to make decisions about disclosure within the workplace easier.

Originality/value

The study has highlighted an understudied area of research in ART populations. The data provide insight into the challenging experiences of individuals combining ART with employment and, in particular, the complexity of decisions about whether or not to disclose.

Responding to Infertility: Lessons From a Growing Body of Research and Suggested Guidelines for Practice

Infertility is a common, yet often misunderstood, experience. Infertility is an important topic for family scientists because of its effects on families; its relevance to research in related areas, such as fertility trends and reproductive health; and its implications for practitioners who work with individuals and couples experiencing infertility. In this review, we focus on common misperceptions in knowledge and treatment of infertility and highlight insights from recent research that includes men, couples, and people with infertility who are not in treatment. The meaning of parenthood, childlessness, awareness of a fertility problem, and access to resources are particularly relevant for treatment seeking and psychosocial outcomes. On the basis of insights from family science research, we provide specific guidelines for infertility practice within broader social contexts such as trends in health care, education, employment, and relationships. Guidelines are presented across three areas of application: infertility education for individuals, families, and practitioners; steps to support the emotional well-being of those affected by infertility; and understanding of treatment approaches and their implications for individuals and couples.

PREVALENCE AND RISK FACTORS OF INFERTILITY IN TURKEY: EVIDENCE FROM DEMOGRAPHIC AND HEALTH SURVEYS, 1993-2013

The inability to have children affects couples worldwide and causes emotional and psychological distress in both men and women. Turkey is a country that lays particular emphasis on the issue of infertility, especially after experiencing a dramatic fertility decline over the last two decades. This study aimed to understand the changes in the prevalence of infertility in Turkey using three different approaches: the DHS Approach, the Constructed Approach and the Current Duration Approach. Furthermore, the factors contributing to elevated risks of infertility as derived from the Constructed Approach were investigated using four different logistic regression models. The data came from the 1993, 1998, 2003, 2008 and 2013 Demographic and Health Surveys conducted by the Hacettepe University Institute of Population Studies. The findings of the Constructed and Current Duration Approaches suggested that the prevalence of infertility decreased markedly from 1993 to 2013 in Turkey. This decline was the result of improvements in maternal health care services in Turkey, as well as an increase in the use of Assisted Reproductive Technology (ART), from 1.9% in 2008 to 4.1% in 2013. The results of the final logistic regression model suggested that the risk of infertility was significantly higher among women aged between 35 and 49 (p<0.01), uneducated women (p<0.01), women whose age at first marriage was over 30 (p<0.01), women defined as overweight (p<0.05) and women whose age at menarche was less than 12 years (p<0.05). This is the first nationwide study to examine the prevalence of infertility and its socio-demographic risk factors in Turkey, a developing country; previous studies have established these risk factors mainly in developed countries.

Prevalence of infertility and help seeking among 15 000 women and men

STUDY QUESTION

What is the prevalence of infertility and of help seeking among women and men in Britain?

SUMMARY ANSWER

One in eight women and one in ten men aged 16–74 years had experienced infertility, defined by unsuccessfully attempting pregnancy for a year or longer, and little more than half of these people sought medical or professional help.

WHAT IS KNOWN ALREADY

Estimates of infertility and help seeking in Britain vary widely and are not easily comparable because of different definitions and study populations.

STUDY DESIGN, SIZE, DURATION

A cross-sectional population survey was conducted between 2010 and 2012 with a sample of 15 162 women and men aged 16–74 years.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants completed the Natsal-3 questionnaire, using computer-assisted personal interviewing (CAPI) and computer-assisted self-interview (CASI).

MAIN RESULTS AND THE ROLE OF CHANCE

The reported prevalence of infertility was 12.5% (CI 95% 11.7–13.3) among women and 10.1% (CI 95% 9.2–11.1) among men. Increased prevalence was associated with later cohabitation with a partner, higher socio-economic status and, for those who had a child, becoming parents at older ages. The reported prevalence of help seeking was 57.3% (CI 95% 53.6–61.0) among women and 53.2% (CI 95% 48.1–58.1) among men. Help seekers were more likely to be better educated and in higher status occupations and, among those who had a child, to have become parents later in life.

LIMITATIONS, REASONS FOR CAUTION

These data are cross-sectional so it is not possible to establish temporality or infer causality. Self-reported data may be subject to recall bias.

WIDER IMPLICATIONS OF THE FINDINGS

The study provides estimates of infertility and help seeking in Britain and the results indicate that the prevalence of infertility is higher among those delaying parenthood. Those with higher educational qualifications and occupational status are more likely to consult with medical professionals for fertility problems than others and these inequalities in help seeking should be considered by clinical practice and public health.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was provided by grants from the Medical Research Council and the Wellcome Trust, with support from the Economic and Social Research Council and the Department of Health. AMJ is a Governor of the Wellcome Trust. Other authors have no competing interests.

Does fertility-specific distress vary by race/ethnicity among a probability sample of women in the United States?

This study explored whether fertility-specific distress varied by race/ethnicity among a nationally representative sample of US women. Participants were 2363 White (n = 1266), Black (n = 569), Hispanic (n = 453), and Asian (n = 51) women who participated in the National Survey of Fertility Barriers. Participants were given the Fertility-Specific Distress Scale and assessed for strength of pregnancy intent, primary versus secondary infertility, and socioeconomic hardship. Black women reported lower levels of fertility-specific distress than White women, but these were fully mediated by the strength of pregnancy intentions. Primary versus secondary infertility and economic hardship were not associated with fertility-specific distress.

IMPAIRED FERTILITY AND PERCEIVED DIFFICULTIES CONCEIVING IN GHANA: MEASUREMENT PROBLEMS AND PROSPECTS

What is the most appropriate measure of impaired fertility for understanding its social consequences in sub-Saharan Africa? The dearth of subjective measures in surveys in the region has prevented comparisons of subjective and objective measures. Perceived difficulties conceiving may have a greater impact than objective measures for social outcomes such as divorce, stigmatization and distress. This study compares 12- (clinical) and 24- (epidemiological) month measures from biomedicine and 5- and 7-year measures from demography with a subjective measure of impaired fertility using correlations, random effects models and test–retest models to assess relationships between measures, their association with sociodemographic characteristics and the stability of measures across time. Secondary panel data (1998–2004) from 1350 Ghanaian women aged 15–49 of all marital statuses are used. Longer waiting times to identification of impaired fertility required by demographic measures result in more stable measures, but perceived difficulties conceiving are most closely aligned with clinical infertility (r=0.61; p<0.05). Epidemiological infertility is also closely aligned with the subjective measure. A large proportion of those identified as having impaired fertility based purely on waiting times are successful contraceptors. Where subjective measures are not available, epidemiological (24-month) measures may be most appropriate for studies of the social consequences of impaired fertility. Accounting for contraceptive use is important in order to avoid false positives. Future research should consider a variety of measures of perceived difficulties conceiving and self-identified infertility to assess which is most valid; in order to accomplish this, it is imperative that subjective measures of infertility be included in social surveys in sub-Saharan Africa.

Evolution of psychology and counseling in infertility

Five key paradigm shifts are described to illustrate the evolution of psychology and counseling in infertility. The first paradigm shift was in the 1930s when psychosomatic concepts were introduced in obstetrics and gynecology as causal factors to explain why some couples could not conceive despite the absence of organic pathology. In the second shift, the nurse advocacy movement of the 1970s stimulated the investigation of the psychosocial consequences of infertility and promoted counseling to help couples grieve childlessness when medical treatments often could not help them conceive. The third shift occurred with the advent of IVF, which created a demand for mental health professionals in fertility clinics. Mental health professionals assessed the ability of couples to withstand the demands of this new high technology treatment as well as their suitability as potential parents. The fourth shift, in the 1990s, saw reproductive medicine embrace the principles of evidence-based medicine, which introduced a much more rigorous approach to medical practice (effectiveness and safety) that extended to psychosocial interventions. The most recent paradigm shift, in the new millennium, occurred with the realization that compliance with protracted fertility treatment depended on the adoption of an integrated approach to fertility care. An integrated approach could reduce treatment burden arising from multiple sources (i.e., patient, clinic, and treatment). This review describes these paradigm shifts and reflects on future clinical and research directions for mental health professionals.

Diagnostic diversity: the role of social class in diagnostic experiences of infertility

Research in the area of the sociology of diagnosis has recently expanded. Despite this development, the foundations of the social aspects of diagnoses, including race, class and gender, are relatively unexplored. Understanding such diversity is important, however, as researchers have shown that diagnoses have significant repercussions on the illness experience. This article is an effort to overcome this gap in the literature by examining class diversity in interpretations and understandings of diagnoses. Using the medicalised condition of infertility as a case example of class differences around diagnoses, I conducted 58 in-depth interviews with infertile women of various class backgrounds in the USA. By comparing the lived experiences of infertility between higher and lower class women, I explore differences in the understanding, interpretation and outcomes of diagnoses, specifically. Furthermore, among lower class women, I examine how they understand infertility outside the medical diagnostic framework. The findings reveal how interpretations and experiences of diagnoses vary depending on an individual's social location. In other words, the study demonstrates that class matters in terms of diagnoses and their understanding.

More research, more responsibility: the expansion of duty to warn in cancer patients considering fertility preservation

Reproductive technology is advancing at a steadfast pace. Researchers are successfully refining options for fertility preservation, to the benefit of the cancer community. Research has consistently shown cancer patients and survivors desire to have risks to fertility and preservation options disclosed, and major campaigns have been undertaken to refer these patients to fertility specialists. However, the decision to pursue fertility preservation is not an isolated judgment. A variety of future decisions may arise for the individual or couple, choices that may not have been relayed during the initial decision-making process. Future decisions include the length of time to continue to store frozen gametes, donating banked gametes to infertile couples, and whether embryos created with one partner would be accepted by a new partner. It is important to continue the advancement of fertility preservation not only in the scientific milieu, but also in addressing a patient's preparedness for long-term decision making.

Revisiting "her" infertility: medicalized embodiment, self-identification and distress

Prior research emphasizes women's distress and responsibility for a couple's infertility because of gendered, pronatalist norms. Yet some studies suggest that being personally diagnosed and/or undergoing treatment differentially shapes reactions. We focused on differences in women's experiences with diagnosis and treatment, conceptualized as the medicalized embodiment of infertility. Using regression analysis, we examined two psychosocial outcomes (self-identification as infertile and fertility-specific distress) in a sample of 496 heterosexual, U.S. women from the National Survey of Fertility Barriers. Medicalized embodiment was salient to women's reactions, but had different relationships to self-identification versus distress. Although women experienced distress regardless of type of diagnosis, they were generally less likely to self-identify as infertile unless personally diagnosed. As such, we cannot assume that all women universally experience infertility. Future research should also address self-identification and distress as separate as opposed to simultaneous psychosocial outcomes.

Race-ethnicity and medical services for infertility: stratified reproduction in a population-based sample of U.S. women

Evidence of group differences in reproductive control and access to reproductive health care suggests the continued existence of "stratified reproduction" in the United States. Women of color are overrepresented among people with infertility but are underrepresented among those who receive medical services. The authors employ path analysis to uncover mechanisms accounting for these differences among black, Hispanic, Asian, and non-Hispanic white women using a probability-based sample of 2,162 U.S. women. Black and Hispanic women are less likely to receive services than other women. The enabling conditions of income, education, and private insurance partially mediate the relationship between race-ethnicity and receipt of services but do not fully account for the association at all levels of service. For black and Hispanic women, social cues, enabling conditions, and predisposing conditions contribute to disparities in receipt of services. Most of the association between race-ethnicity and service receipt is indirect rather than direct.

Psychosocial trends in couples prior to commencement of in vitro fertilisation (IVF) treatment

Facing infertility and undergoing fertility treatment can create emotional turmoil in couples' lives. It is essential for fertility therapy providers to assess the coping and communication strategies of couples before treatment in order to provide appropriate support. We performed a two time point (year 2003 & year 2009) cross-sectional study of patients attending our services to undergo in vitro fertilisation. All couples attending the Human Assisted Reproduction Ireland Unit, a tertiary referral academic centre at the Rotunda Hospital, were requested to complete a psychosocial questionnaire before commencing the treatment. The questions assessed couples' understanding of their own infertility, family background and support, relationship traits and stress levels prior to commencing fertility treatment. A total of 180 patients participated in the study. Our findings showed that within a 6-year time span, couples' attitudes have changed significantly. Compared to 6 years ago, couples now have a better understanding of infertility and are seeking treatment quicker. Interestingly, we showed higher stress levels nowadays with fewer couples following routine stress management. We also identified specific gender differences in that women have a more open attitude in discussing infertility and seeking more support from friends and family compared to men.

Resilience in infertile couples acts as a protective factor against infertility-specific distress and impaired quality of life

OBJECTIVE

Our hypothesis was that resilience (=psychosocial stress-resistance) reduces infertility-specific distress and maintains quality of life of infertile couples.

METHODS

Questionnaire data of WHO Quality of Life assessment (WHOQOL; domains: 'physical', 'psychological', 'social relationships' and 'environment'), Fertility Problem Inventory (FPI; scales: 'social concern', 'sexual concern', 'relationship concern', 'rejection of childfree lifestyle' and 'need for parenthood'), Resilience Scale (RS), as well as sociographic and medical data were available for 199 infertile couples.

RESULTS

Age, medical diagnosis and 'intensity of desire for a child' had no influence on quality of life. High scores on 'suffering from childlessness' went along with less satisfaction on 'physical' and 'psychological' domains for the women only. For both partners, high scores on 'suffering from childlessness' went along with higher scores on all FPI scales. High resilience was associated with high scores on all WHOQOL domains for both partners, also with low scores on all FPI scales except for 'need for parenthood' for the women and with a low score only on 'relationship concern' for the men.

CONCLUSIONS

For infertile couples, resilience can be considered as an unspecific protective factor against infertility-specific distress and impaired quality of life. When offering counselling to involuntarily childless couples, awareness should be raised for resilience as a couple's resource and a "generic" factor of coping.

Infertility treatment and fertility-specific distress: A longitudinal analysis of a population-based sample of U.S. women

Because research on infertile women usually uses clinic-based samples of treatment seekers, it is difficult to sort out to what extent distress is the result of the condition of infertility itself and to what extent it is a consequence of the experience of infertility treatment. We use the National Survey of Fertility Barriers, a two-wave national probability sample of U.S. women, to disentangle the effects of infertility and infertility treatment on fertility-specific distress. Using a series of ANOVAs, we examine 266 infertile women who experienced infertility both at Wave 1 and at Wave 2, three years later. We compare eight groups of infertile women based on whether or not they have received treatment and on whether or not they have had a live birth. At Wave 1, infertile women who did not receive treatment and who had no live birth reported lower distress levels than women who received treatment at Wave 1 only, regardless of whether their infertility episode was followed by a live birth. At Wave 2, women who received no treatment have significantly lower fertility-specific distress than women who were treated at Wave 1 or at Waves 1 and 2, regardless of whether there was a subsequent live birth. Furthermore, fertility-specific distress did not increase over time among infertile women who did not receive treatment. The increase infertility-specific distress was significantly higher for women who received treatment at Wave 2 that was not followed by a live birth than for women who received no treatment or for women who received treatment at Wave 1 only. These patterns suggest that infertility treatment is associated with levels of distress over and above those associated with the state of being infertile in and of itself.

Variation in distress among women with infertility: evidence from a population-based sample

BACKGROUND

We examine variation in fertility-specific distress (FSD) and general distress according to different experiences of infertility among 1027 US women who have experienced infertility within the previous 10 years.

METHODS

General distress was measured by a short form of the Center for Epidemiological Studies-Depression. Multiple regression analysis was conducted on self-report data (based on a telephone interview) from a probability-based sample of US women aged 25-45 years. We compare women with infertility who have had a prior pregnancy (secondary infertility, n = 628) to women with infertility with no prior pregnancies (primary infertility, n = 399). We further distinguish between women with infertility who were actually 'trying' to become pregnant (the infertile with intent) with those who met the medical definition of infertile but did not describe themselves as trying to become pregnant (infertile without intent).

RESULTS

Both types of infertility (primary versus secondary) (β = 0.31*) and intentionality (infertile with and without intent) (β = 0.08*) are associated with FSD. These associations persist when we control for resource and demographic variables, life course variables, social support and social pressure variables. General distress does not vary by infertility type or intentionality.

CONCLUSIONS

Results reveal variation in women's recalled experiences of infertility and that FSD is more sensitive to effects of different experiences than general distress. Women with primary infertility who were explicitly trying to become pregnant at the time of the infertility episode stand out as a particularly distressed group. Caregivers should be aware that the emotional needs of women with primary infertility may differ from those with secondary infertility.

Specifying the effects of religion on medical helpseeking: the case of infertility

Several recent studies have examined the connection between religion and medical service utilization. This relationship is complicated because religiosity may be associated with beliefs that either promote or hinder medical helpseeking. The current study uses structural equation modeling to examine the relationship between religion and fertility-related helpseeking using a probability sample of 2183 infertile women in the United States. We found that, although religiosity is not directly associated with helpseeking for infertility, it is indirectly associated through mediating variables that operate in opposing directions. More specifically, religiosity is associated with greater belief in the importance of motherhood, which in turn is associated with increased likelihood of helpseeking. Religiosity is also associated with greater ethical concerns about infertility treatment, which are associated with decreased likelihood of helpseeking. Additionally, the relationships are not linear throughout the helpseeking process. Thus, the influence of religiosity on infertility helpseeking is indirect and complex. These findings support the growing consensus that religiously-based behaviours and beliefs are associated with levels of health service utilization.

"Trying" times: Medicalization, intent, and ambiguity in the definition of infertility

Researchers studying infertility from the perspective of anthropology and other the social sciences seldom examine the assumptions embedded in the biomedical definition of infertility. Implicit in the biomedical definition is the assumption that people can be divided straightforwardly into those who are trying to conceive and those who are not trying to conceive. If being infertile implies "intent to conceive," we must recognize that there are various degrees of intent and that the line between the fertile and the infertile is not as sharp as is usually imagined. Drawing on structured interview data collected from a random sample of Midwestern U.S. women and from qualitative interviews, we demonstrate that that there is a wide range of intent among those classified as infertile according to the biomedical definition. We explore the implications of this for research.

The experience of infertility: a review of recent literature

About 10 years ago Greil published a review and critique of the literature on the socio-psychological impact of infertility. He found at the time that most scholars treated infertility as a medical condition with psychological consequences rather than as a socially constructed reality. This article examines research published since the last review. More studies now place infertility within larger social contexts and social scientific frameworks although clinical emphases persist. Methodological problems remain but important improvements are also evident. We identify two vigorous research traditions in the social scientific study of infertility. One tradition uses primarily quantitative techniques to study clinic patients in order to improve service delivery and to assess the need for psychological counselling. The other tradition uses primarily qualitative research to capture the experiences of infertile people in a sociocultural context. We conclude that more attention is now being paid to the ways in which the experience of infertility is shaped by social context. We call for continued progress in the development of a distinctly sociological approach to infertility and for the continued integration of the two research traditions identified here.

The epidemiology of infertility in the North East of Scotland

BACKGROUND

There is a perception that the prevalence of infertility is on the rise. This study aimed to determine the current prevalence of infertility in a defined geographical population, ascertain changes in self-reported infertility over time and identify risk factors associated with infertility.

METHODS

A postal questionnaire survey of a random population-based sample of women aged 31-50 years was performed in the Grampian region of Scotland. Questions addressed the following areas: pregnancy history, length of time taken to become pregnant each time, whether medical advice had been sought and self-reported exposure to factors associated with infertility.

RESULTS

Among 4466 women who responded, 400 (9.0%) [95% CI 8.1, 9.8] had chosen not to have children. Of the remaining 4066 women, 3283 (80.7%) [95% CI 79.5, 82.0] reported no difficulties in having children and the remaining 783 (19.3%) [95% CI 18.1, 20.5] had experienced infertility, defined as having difficulty in becoming pregnant for more than 12 months and/or seeking medical advice. In total 398 (9.8%) [95% CI 8.9, 10.7] women had primary infertility, 285 (7.0%) [95% CI 6.2, 7.8] had secondary infertility, 100 (2.5%) [95% CI 2.0, 2.9] had primary as well as secondary infertility. A total of 342 (68.7%) and 208 (73.0%) women with primary and secondary infertility, respectively, sought medical advice and 202 (59.1%) and 118 (56.7%) women in each group subsequently conceived. History of pelvic surgery, Chlamydial infection, endometriosis, chemotherapy, long-term health problems and obesity were associated with infertility. In comparison with a similar survey of women aged 46-50 from the same geographical area, the prevalence of both primary infertility (>24 months) [70/1081, (6.5%) versus 68/710 (9.6%) P = 0.02] and secondary infertility [29/1081 (2.7%) versus 40/710 (5.6%) P = 0.002] were significantly lower.

CONCLUSIONS

Nearly one in five women attempting conception sampled in this study experienced infertility, although over half of them eventually conceived. Fertility problems were associated with endometriosis, Chlamydia trachomatis infection and pelvic surgery, as well as obesity, chemotherapy and some long-term chronic medical conditions. There is no evidence of an increase in the prevalence of infertility in this population over the past 20 years.

Partnered Decisions? U.S. Couples and Medical Help-seeking for Infertility

We examined male partners' influence on the decision to seek medical help for infertility using from the National Survey of Fertility Barriers. Building upon an existing help-seeking framework, we incorporated characteristics of both partners from 219 heterosexual couples who had ever perceived a fertility problem. In logistic regression analyses, we found an association between couple-level attitudes and medical help-seeking even when other predisposing and enabling conditions existed. Overall, the findings highlight that both partners contribute to the infertility help-seeking process, and that different factors may play a role in different stages of help-seeking. Studies of infertility help-seeking need to be more inclusive of the context that these decisions are embedded within to better understand service use.

The hidden infertile: infertile women without pregnancy intent in the United States

A national probability sample reveals two relatively distinct groups of infertile women: those with intent, who have experienced a period of 12 or more months during which they tried to conceive but did not, and those without intent, who had a period of at least 12 months during which they could have conceived and did not but who do not describe themselves as having tried to become pregnant at that time. Those with intent are more likely to identify as having a fertility problem, to be distressed, and to pursue infertility treatment than those without intent, suggesting that many women do not realize that they meet the medical criteria for infertility and may wait longer to get help, therefore lowering their chances of conception.

When do involuntarily infertile couples choose to seek medical help?

OBJECTIVE

To estimate the probability of medical consultation for infertility during the course of a pregnancy attempt and to study its determinants.

DESIGN

Pregnancy-based retrospective telephone survey analyzed with a discrete time Cox model.

SETTING

Two rural counties in Brittany and Normandy, France.

PATIENT(S)

A random sample of 901 women from the general population aged 18-60 years reporting 1,460 pregnancy attempts resulting in a live birth between 1985 and 2000 (participation rate, 73%).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Probability of medical consultation for involuntary infertility cumulated over time.

RESULT(S)

The cumulative probability of medical consultation for involuntary infertility among nulligravid women was 45% after 12 months of involuntary infertility and 75% after 24 months. The probability of medical consultation at any time was half that for parous women (odds ratio 0.4, 95% confidence interval 0.2-0.6). More highly educated women were more likely to have sought medical help for infertility. Only 45% of women who had sought medical advice received infertility treatment.

CONCLUSION(S)

Our survival approach provides a description of infertility service use during the course of a pregnancy attempt, and confirms that parity and educational level are strong predictors of medical help-seeking behaviors.

Implications of psychosocial support in infertility--a critical appraisal

OBJECTIVE

Various psychosocial interventions have been recommended for infertile persons, but it remains unclear what their implications are, and if some of them might even be harmful under certain circumstances.

METHODS

A survey is given of papers concerning the usefulness of psychosocial support in infertility.

RESULTS

Providing procedural information concerning the technical aspects of infertility investigation probably facilitates coping with infertility and with assisted reproductive techniques. This information can be given in the form of booklets or educational films. Using the Internet is a fast and easy way to obtain information on infertility and its treatment, but with the risk of getting wrong or misleading information. Telephone counseling can be helpful in providing specific information about the infertility workup but it cannot replace face-to-face counseling on distressing psychosocial issues. Attendance at support groups can be recommended to strengthen coping abilities. Psychosocial counseling and psychotherapy are definitely effective in reducing negative affect, mostly within a short period of time (less than 10 sessions). Pregnancy rates are unlikely to be affected by psychosocial interventions.

CONCLUSION

Infertility counseling and support groups seem to be the most efficient psychosocial interventions in infertility. Therefore, infertility counseling should be available at all stages of medical therapy, and it should be free of charge for the persons attending it. Course, content and goals of the infertility counseling should be made transparent. The efficacy of support groups has to be evaluated more systematically. Several methodological questions have to be solved yet, and the generalizability of these results is still restricted.

Decision-making about seeking medical advice in an internet sample of women trying to get pregnant

INTRODUCTION

In light of the near universal desire to become a parent one would expect most people to seek medical advice if they were experiencing difficulties conceiving. Yet less than 55% do so and we sought to understand more about this paradox by comparing the psychosocial profile and decision-making of women not yet engaged in the medical process to that of those who had consulted.

METHODS

A Fertility Decision-Making Questionnaire was designed and posted on a website dedicated to women trying to conceive.

RESULTS

A total of 426 women completed the questionnaire, 56% had not yet consulted a doctor about conceiving (non-consulter, NC). Women who had sought treatment had more positive treatment beliefs, and a greater willingness to know if a problem existed, than those who had not yet consulted. Almost 20% of NC women already met the medical definition of infertility and this subgroup had a greater fear of discovering a problem and of being labelled infertile than other women in the study.

CONCLUSIONS

Seeking medical advice for fertility problems is mainly associated with what women know or want to know about their fertility and their emotional reactions to that knowledge. Negative reactions can substantially delay seeking help in 20% of women.

International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care

INTRODUCTION The purpose of the present study was to review existing population surveys on the prevalence of infertility and proportion of couples seeking medical help for fertility problems. METHODS Population surveys, reporting the prevalence of infertility and proportion of couples seeking help in more and less developed countries, were reviewed. RESULTS Estimates on the prevalence of infertility came from 25 population surveys sampling 172 413 women. The 12-month prevalence rate ranged from 3.5% to 16.7% in more developed nations and from 6.9% to 9.3% in less-developed nations, with an estimated overall median prevalence of 9%. In 17 studies sampling 6410 women, the proportion of couples seeking medial care was, on average, 56.1% (range 42-76.3%) in more developed countries and 51.2% (range 27-74.1%) in less developed countries. The proportion of people actually receiving care was substantially less, 22.4%. Based on these estimates and on the current world population, 72.4 million women are currently infertile; of these, 40.5 million are currently seeking infertility medical care. CONCLUSIONS The current evidence indicates a 9% prevalence of infertility (of 12 months) with 56% of couples seeking medical care. These estimates are lower than those typically cited and are remarkably similar between more and less developed countries.

Psychological distress by type of fertility barrier

BACKGROUND

We examined fertility-specific distress (FSD) and general distress by type of fertility barrier (FB).

METHODS

In a random sample telephone survey, 580 US women reported their fertility intentions and histories. Six groups of women were identified: (i) no FBs, (ii) infertile with intent, (iii) infertile without intent, (iv) other fertility problems, (v) miscarriages and (vi) situational barriers. Multiple regression analyses were used to compare groups with FBs.

RESULTS

Sixty-one percent reported FBs and 28% reported an inability to conceive for at least 12 months. The infertile with intent group had the highest FSD, which was largely explained by (a) self-identification as infertile and (b) seeking medical help for fertility. The no FB group had a mean Center for Epidemiological Studies Depression scale score above the commonly used cut-off of 16, although 23% of the women with FBs did score above 16.

CONCLUSIONS

FBs are common. Self-identification as infertile is the largest source of FSD. More women with FBs had elevated general distress than women without FBs; mean general distress was below 16 for all FB groups. It may be that, for some women (even those with children), FBs can have lasting emotional consequences, but many women do heal from the emotional distress that may accompany fertility difficulties.

Psychosocial aspects of surrogate motherhood

This review addresses the psychosocial research carried out on surrogacy triads (surrogate mothers, commissioning mothers and offspring) and shows that research has focused on a number of specific issues: attachment and disclosure to surrogate offspring; experiences, characteristics and motivations of surrogate mothers; and changes in profiles of the commissioning/intended mothers. Virtually all studies have used highly selected samples making generalizations difficult. There have been a notable lack of theory, no interventions and only a handful of longitudinal studies or studies comparing different populations. Few studies have specifically questioned the meaning of and need for a family or the influence and impact that professionals, treatment availability and financial factors have on the choices made for surrogate and intended mothers. Societal attitudes have changed somewhat; however, according to public opinion, women giving up babies still fall outside the acceptable remit. Surrogate and intended mothers appear to reconcile their unusual choice through a process of cognitive restructuring, and the success or failure of this cognitive appraisal affects people's willingness to be open and honest about their choices. Normal population surveys, on the contrary, are less accepting of third party reproduction; they have no personal need to reconsider and hence maintain their original normative cognitively consonant state.