NURSING DEPARTMENT, MEDICINE AND HEALTH COLLEGE
Lishui University, China FACULTY OF HEALTH AND OCCUPATIONAL STUDIES
Department of Caring Sciences
The Experience of Women Having Infertility
A Descriptive Review
Li Xin (Cindy)
Wang Yanan (Susan)
2020
Student thesis, Bachelor degree, 15 credits Nursing
Abstract
Background: In recent years, the incidence of infertility has been increasing, and infertility
has become a universal health problem. Infertility often leads to mental health problems of couples. Among these couples, female tends to suffer greater psychological impact than male. Understanding the experiences of infertile women is of great significance in the treatment of infertility.
Aim: To describe the experiences of women having infertility.
Design: A descriptive review of qualitative studies.
Method: Articles were searched in the databases PubMed and CINAHL. The selected
articles summarize the similarities and differences in the experiences of women with infertility through multiple readings and analyses.
Results: A total of 10 articles are included in the review. Four themes are derived from the
results: 1) Pressure from family; 2) Suffering violence; 3) Emotional expressions; 4) Coping strategies. The infertile women experience pressure from family, not only from husbands but also from relatives. They suffer violence, including physical abuse and psychological abuse. Faced with infertility, these women express their emotions such as social isolation, stigma, lacking of control, depression and stress. In addition, they also adopt coping strategies.
Conclusions: Pressure from family, violence, stigma, lack of control and other negative
emotions cause great distress to infertile women. Although some of them have taken measures to cope with these feelings, they are vulnerable at heart and need the care of nurses. Nurses need to understand the experiences of infertile women, help them relieve stress and avoid violence, provide them with more effective psychological care, guide them to cope with these feelings properly, and promote their health.
Content
1. Introduction ... 1
1.1 Background ... 1
1.2 Infertility-Definition ... 1
1.3 The nurse’s role ... 1
1.4 Nursing theory ... 2
1.5 Early reviews ... 2
1.6 Problem statement ... 3
1.7 Aim and specific question ... 3
2. Method ... 3 2.1 Design ... 3 2.2 Search strategy ... 4 2.3 Selection criteria ... 5 2.4 Selection process ... 5 2.5 Data analysis ... 6 2.6 Ethical considerations ... 6 3. Results ... 7
3.1 Pressure from family ... 7
3.1.1 Pressure from husbands ... 7
3.1.2 Pressure from relatives ... 8
3.2 Suffering Violence ... 8 3.2.1 Physical abuse ... 8 3.2.2 Psychological abuse ... 8 3.3 Emotional expressions ... 9 3.3.1 Social isolation ... 9 3.3.2 Stigma ... 9 3.3.3 Lack of control... 10
3.3.4 Depression & Stress ... 10
3.4 Coping strategies ... 10
3.4.1 Active coping ... 10
3.4.2 Negative coping ... 11
4. Discussion ... 12
4.1 Main results ... 12
4.2 Results discussion ... 12
4.2.1 Pressure from family ... 12
4.2.2 Suffering Violence ... 12
4.2.3 Emotional expressions ... 13
4.2.4 Coping strategies ... 14
4.3 Methods discussion ... 14
4.4 Clinical implication for nursing ... 15
4.5 Suggestions for further research ... 15
5. Conclusions ... 16
6. Reference ... 17
1
1. Introduction
1.1 Background
In recent years, the rate of infertility has been increasing rapidly. In 2002, the world health organization estimated that about 80 million people worldwide were affected by infertility (WHO, 2002). According to statistics, about 186 million people worldwide will be infertile, with the average infertility rate between 8% and 12% by 2018 (Inhorn & Patrizio, 2015). According to statistics, one in seven couples in the west and one in four in developing countries are infertile. Population trends vary widely in different regions of the world, with rapid population growth and high fertility rates in the poorest countries, particularly in sub-Saharan Africa, while population decline, aging and very low fertility are of concern to many developed countries (Borght & Wyns, 2018). In recent years, the decline in the number of births per woman (from 2.5 children in 2010-2015 to 2.0 children in 2095- 2100), and the increasing rates of childlessness, both raise concerns about the future of the next generation (United Nations 2015). In addition, infertility often leads to mental problems of couples. In the past, estimates of the prevalence of psychiatric problems in infertile couples ranged from 25 to 60 percent. The incidence of depression and anxiety in infertile couples is significantly higher than in fertile controls and in the general population respectively. Psychological impact of infertility is greater in women than in men (Berardis et al., 2014).
1.2 Infertility-Definition
Infertility is a reproductive health disorder that affects men, women and couples (Gurunath
et al., 2011). In 2016, World Health Organization (WHO) defined infertility as the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse from a clinical/medical perspective (WHO, 2016).They divided infertility into two main groups: primary and secondary, the primary infertility is the inability to become pregnant or to carry a baby of woman who has never carried a child through more than a year of unprotected sexual intercourse, while the secondary is the inability to become pregnant or to carry a baby of woman who has previously given birth to a child (WHO, 2016).
1.3 The nurse’s role
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promote their mental health, and reduce their emotional pain. Nurses are expected to provide care based on respect for their privacy and human rights. In terms of psychological and emotional care, nurses can create a harmonious, warm and supportive environment for women with infertility, use psychological counseling methods to vent their emotions, and guide them to relieve tension and depression (Chen & Yu, 2006).
1.4 Nursing theory
Transitions theory was put forward by Meleis, and it was developed in 1971. Transition theory points out that transition includes developmental transition, health and illness, situation, and organization transition (Meleis & Trangenstein, 1994; Schumacher & Meleis, 1994). These transitions are complex and multiple (Meleis et al., 2000). Individual, community, or social factors may accelerate or hinder the process and outcome of a healthy transition (Meleis et al., 2000). In addition, the transition theory also mentions the concept of people, environment, health and nursing (Schumacher & Meleis, 1994; Meleis et al., 2000). Transition involves a movement process and changes in basic life patterns that lead to changes in identity, roles, relationships, abilities and behaviors and environmental conditions may affect the individual process or outcome of transition (Schumacher & Meleis, 1994; Meleis et al., 2000).
In connection with this research topic, women' s identities, roles, relationships, and their behavior and lifestyle can be changed by infertility (Raile Alligod & Marriney Tomey). Because of infertility, women may not be able to be mothers, their relationship with their husbands and society may be alienated, and they may avoid the normal contact of society.Under the long-term influence of social environment and family concept, it can cause potential psychological harm to women with infertility, such as depression or anxiety (Raile Alligod & Marriney Tomey).
1.5 Early reviews
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showed that fertility was the ability to establish a clinical pregnancy and infertility was a disease characterized by the failure to establish a clinical pregnancy after 12 months of regular and unprotected sexual intercourse (Zegers-Hochschild et al., 2017; WHO, 2016). The results also indicated that infertility affected 8 to 12 percent of reproductive couples worldwide, and secondary infertility was the most common form of global female infertility (Ombelet et al., 2008; Nachtigall et al., 2006). In addition, the results found out that the time of unwanted non-conception, age of the female partner and disease-related infertility influenced the spontaneous fertility of couples (Gnoth et al., 2005). Romeiro’s study was to explore the spiritual aspects of patients with infertility and discover the deeper meaning of unconscious childless experiences (Romeiro et al., 2017). The results of it confirmed that infertility couples had spiritual needs and unmet parental needs and they could choose to combine spiritual coping strategies (Romeiro et al., 2017). Mothers had higher stress levels than fathers and sought social support more frequently.
1.6 Problem statement
Infertility is globally regarded as a disabling issue affecting public health, the rate of infertility has been increasing rapidly. Under the specific cultural background and social environment, the pressure on infertile women is undoubtedly huge. Numerous women suffer from depression as a result of infertility, which is harmful to both the individual and the family.
A great number of researchers have studied infertility in the past. Previous reviews showed a causal relationship between psychopathology and infertility. It also showed that infertility caused couples to have spiritual needs and unmet parental needs, and they chose to adopt spiritual coping strategies. However, there has been little research on the experience of infertile women. Therefore, this study can provide information about the experience of women who are infertile, help nurses understand their experiences and their feelings, so as to provide better care for them.
1.7 Aim and specific question
The aim is to describe the experience of women having infertility.
The research question is how do women describe their experience of having infertility?
2. Method
2.1 Design
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2.2 Search strategy
The literature search was conducted across two scientific databases including Cinahl andPubMed (Polit & Beck, 2012). The databases were specifically related to the aim of this review. The Cinahl database used keywords: “Infertility”, “Women”, “Experiences OR perceptions OR feelings OR views”. PubMed database used: “Infertility”, “Female”, “Experiences OR perceptions OR feelings OR views”.Indexed search terms were derived from MeSH and Cinahl headings. Using the Boolean operator “AND”, “OR” (Polit & Beck, 2012). And the limitations were “Ten years” and “English” (Polit & Beck, 2012). In the preliminary search (see Table 1), titles and abstracts of 1249 articles were browsed and read, and 37 articles that might be useful for literature review were selected.
Table 1. Outcomes of database searches Database Limits and
search date
Search terms Number of hits Possible articles (excluding doubles) Medline via PubMed 10years, English 2019-5-17 “Infertility”[MeSH] 17777 Medline via PubMed 10years, English 2019-5-17 "Female"[MeSH] 8901 Medline via PubMed 10years, English 2019-5-17 “Infertility”[MeSH] AND "Female"[MeSH] AND “Experiences” OR “Perceptions” OR “Feelings” OR “Views” 607 12 Cinahl Search 10years, English 2019-5-17
“Infertility” AND "Women" AND “Experiences OR perceptions OR feelings OR views”
642 25
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2.3 Selection criteria
Exclusion criteria used by the authors were articles that were quantitative studies or reviews, and studies focused on the experiences of men with infertility or the experiences of nurses with caring infertile women.
Inclusion criteria for articles were that they were related to the aim of the review study (to describe the experience of women having infertility), and could answer the research questions, empirical scientific articles that used qualitative approach.
2.4 Selection process
The authors used PubMed and CINAHL databases. There were 607 initial articles searched in PubMed, 642 initial articles searched in Cinahl. In addition, according to the inclusion criteria, aim and research questions, authors added an article from the reference of selected articles. At first, there were 899 articles recorded in total without duplicate articles. After that, the authors selected 78 articles according to the title of the articles and screened out the literature reviews. Then the authors checked the abstracts of the articles and selected 37 articles. Finally, the authors selected 10 articles. The reasons for excluding the 27 articles were that: 21 articles were quantitative researches, and 6 articles were not experiences of women with infertility (see Figure1)
Records identified through database searching
(n = 1249)
(Cinahl: 642; PubMed: 607)
Additional records identified through Manual search: Relevance for inclusion criteria, aim and specific questions from the reference of the selected articles (n = 1)
Records after duplicates removed (n = 899)
Records excluded:(n = 821) - Not related to the aim of the study (n = 723)
- Not infertility (n = 98) Records screened
(n = 78)
Records excluded after screened: (n = 41)
- Describe the experiences of men(n = 22)
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Fig1. The selection process of articles.
2.5 Data analysis
For this literature review, firstly the authors searched a significant number of articles and then read the articles multiple times to select the suitable ones. The authors kept the aim and research questions in mind throughout the selection process. Selected articles were labeled with alphabet codes, which facilitated the analysis of research results (A-J) (Appendix 1) (Lommi et al., 2015). The authors gave a general description of the relevant details of the selected articles, including: articles' authors, titles, designs/possible approaches, participants, data collection methods and data analysis methods, see appendix 1. The authors focused on the “results” sections of these articles by reading and re-reading them, and then listed the authors, aims and results of the articles in appendix 2. These processes made it convenient for the authors to summarize and categorize each topic (Polit & Beck, 2012). These results were discussed and analyzed by the authors, after which their similarities and differences were summarized and they were divided into different categories at last. Four themes and ten categories were summarized in Appendix 3.
2.6 Ethical considerations
This research focused on the experiences of women having infertility, and relevant articles were read and reviewed objectively without plagiarism. At the same time the authors objectively present the results through repeating discussion, analyzing, as well as summarizing them in their own words. The authors use references reasonably in a correct format.
Records included after abstract screened
(n = 37)
Studies included in the review
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3. Results
The results were based on 10 articles with qualitative approaches. These articles were all about the experiences of women having infertility, which include pressure from family, suffering violence, emotional expressions, as well as coping strategies. The themes and categories of the results were presented in table 2.
Table 2. The Themes and Categories of the results.
Themes Categories
Pressure from family
Pressure from husbands Pressure from relatives
Suffering Violence Physical abuse
Psychological abuse
Emotional expressions
Social isolation Stigma Lack of control Depression & Stress
Coping strategies
Active coping Negative coping
3.1 Pressure from family
3.1.1 Pressure from husbands
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that their husband would find another woman and choose to remarry (Dierickx et al., 2018; Cunningham & Cunningham, 2013；Behboodi-Moghadam et al., 2012).
3.1.2 Pressure from relatives
Pressure from relatives was also an important factor that affects the infertile women, and this part was mentioned in four articles (Daibes et al., 2017; Tiu et al., 2018; Dierickx et al., 2018; Nguimfack et al., 2017).Numerous infertile women reported that they felt strained with their relatives (Daibes et al., 2017; Tiu et al., 2018; Dierickx et al., 2018; Nguimfack et al., 2017). When their in-laws were told that they could not have children, the in-laws were unhappy and angry with them, and even put pressure on their husbands and persuaded them to divorce (Tiu et al., 2018; Dierickx et al., 2018). They were often obedient and subservient to their in-laws, needed to consider their parents’ feelings, and even those of other relatives (Daibes et
al., 2017; Tiu et al., 2018; Dierickx et al., 2018; Nguimfack et al., 2017). In addition, some
infertile women also experienced pressure from their biological parents who perceived them as a failure, which made them feel abandoned and marginalized (Nguimfack et al., 2017).
3.2 Suffering Violence
3.2.1 Physical abuse
Three qualitative approaches looked at physical violence caused by infertility (Daibes et al., 2017; Dierickx et al., 2018; Behboodi-Moghadam et al., 2012). Some infertile women said that their husbands were faced with family pressure of having a baby, and thus becoming moody, irritable and often violent against them(Daibes et al., 2017). In response to domestic violence of their husbands, some infertile women remained silent to avoid being known about their infertility, while others chose to resist and scuffle with their husbands (Dierickx et al., 2018; Behboodi-Moghadam et al., 2012).
3.2.2 Psychological abuse
Psychological abuse was also a common topic of numerous studies, among which four qualitative studies had proposed similar views (Daibes et al., 2017; Cunningham & Cunningham, 2013; Behboodi-Moghadam et al., 2012; Fledderjohann, 2012). Infertile women described that they were often subjected to psychological abuse from the family or society because of infertility (Daibes et al., 2017; Cunningham & Cunningham, 2013; Behboodi-Moghadam et al., 2012; Fledderjohann, 2012). As for the psychological abuse from family, they would be scolded and humiliated by the husband and his family, and they could only endure and bear the pressure alone (Daibes et al., 2017; Behboodi-Moghadam et
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children, and were often reminded of their incompleteness by their husbands; Husbands' families would criticize and accuse them of infertility, and even let their husbands choose to distance themselves or remarry (Daibes et al., 2017; Behboodi-Moghadam et al., 2012). Of course, infertile women also suffered from psychological abuse from society. These women reported that their infertility was questioned and talked about by neighbors and even other strangers, which made them feel ashamed and monitored as their private affairs were exposed to the public (Daibes et al., 2017).
3.3 Emotional expressions
3.3.1 Social isolation
One aspect of the emotional expressions of infertile women was social isolation. Eight studies reported that infertile women experience social isolation (Boz & Okumus, 2017; Yao
et al., 2017; Daibes et al., 2017; Tiu et al., 2018; Batool & de Visser, 2012; Cunningham &
Cunningham, 2013; Behboodi-Moghadam et al., 2012; Fledderjohann, 2012). For most infertile women, the experience of social isolation brought by infertility had been troubling them, and they said they did not like social activities or even cut off social activities to choose solitude (Daibes et al., 2017; Behboodi-Moghadam et al., 2012). They were increasingly isolated from friends and colleagues who have children and chose to create childless social networks (Tiu et al., 2018; Batool & de Visser, 2012). Because they felt excluded from the fertile world, unable to participate in social gatherings of children, and did not want to discuss their friends gossip about infertility (Boz & Okumus, 2017; Yao et al., 2017; Daibes et al., 2017; Tiu et al., 2018; Batool & de Visser, 2012; Cunningham & Cunningham, 2013; Behboodi-Moghadam et al., 2012; Fledderjohann, 2012).
3.3.2 Stigma
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3.3.3 Lack of control
Women also expressed that their lack of control because of infertility. Women' s life after knowing that they were infertile could be new, strange and unknown, and they needed to face conflicting choices about whether to continue treatment and other strong social, cultural and religious ambivalence (Boz & Okumus, 2017). They showed that they would feel they were slowly losing control of all: their lives were dominated by events related to infertility, their daily lives and social roles changed; their future was out of control and in the hands of infertility therapists (Boz & Okumus, 2017; Cunningham & Cunningham, 2013).
3.3.4 Depression & Stress
When women faced infertility, depression and stress would be their most emotional expressions. Depression and stress were mentioned in six articles (Dierickx et al., 2018; Nguimfack et al., 2017; Batool & de Visser, 2012; Cunningham & Cunningham, 2013; Behboodi-Moghadam et al., 2012; Fledderjohann, 2012). When women knew that they could not have children, they reported that they often suffered from lower self-esteem, thinking that they were not perfect and they were losers, as well as that they were sorry for their husbands because they could not have children for them (Nguimfack et al., 2017; Cunningham & Cunningham, 2013; Behboodi-Moghadam et al., 2012). In addition, some infertile women stated that they were also faced with treatment choices, difficulties in the treatment process and economic challenges brought by treatment (Dierickx et al., 2018; Cunningham & Cunningham, 2013). These problems caused infertile women to experience depression and stress, low energy levels, sleep disturbances and loss of confidence (Batool & de Visser, 2012; Fledderjohann, 2012).
3.4 Coping strategies
3.4.1 Active coping
Certainly, infertile women also had strategies for dealing with infertility. Four studies report that they would adopt active strategies to face to infertility (Daibes et al., 2017; Tiu et al., 2018; Nguimfack et al., 2017; Batool & de Visser, 2012). Some infertile women reported that they would overcome negative emotions to maintain a positive attitude towards infertility, they often thought that the disease was beneficial or positive and thanked them for not being in a worse situation, and they would choose to do housework, work or other meaningful activities to make their lives busy and meaningful (Tiu et al., 2018; Batool & de Visser, 2012). Some women said that they used religion as an important platform to hope for pregnancy and firmly believed that they would have children of their own (Daibes et al., 2017; Nguimfack
11
of actively trying to get pregnant, and they received a lot of medical advice (Daibes et al., 2017).
3.4.2 Negative coping
In addition, there were some infertile women who reported that they chose to react negatively to face the infertility. Some infertile women chose to avoid passively in order to face infertility, gave up or submit to religion, and some even felt cynical and frustrated towards god, believing that god had deprived them of their children, and began to blame him (Batool & de Visser, 2012). Some women chose to quit, because they needed to face the difficulty of treatment and unknown future (Cunningham & Cunningham, 2013).
3.5 The chosen articles information
Through sorting out the 10 articles used in the literature review, it was found that all the articles described the methods of data collection.
These ten studies were from six countries: Japan (Behboodi-Moghadam et al., 2012), UK (Batool & de Visser, 2012; Cunningham & Cunningham, 2013; Daibes et al., 2017; Fledderjohann, 2012), Taiwan (Boz & Okumus, 2017), Belgium (Dierickx et al., 2018), Australia (Nguimfack et al., 2017), Hong Kong (Tiu et al., 2018; Yao et al., 2017).
In seven of the chosen articles, it was made clear that authors performed semi-structured interviews with the study participants (Behboodi-Moghadam et al., 2012; Batool &de Visser, 2012; Daibes et al., 2017; Fledderjohann, 2012; Nguimfack et al., 2017; Yao et al., 2018). In one of the chosen articles, in-depth and semi-structured interviews in the form of focus groups were employed (Tiu et al., 2018). However, in the study by Boz & Okumus (2017), the authors used Diary entries. In the study by Cunningham N & Cunningham T(2013), the authors chose asynchronous online life-story interviews. And the authors combined semi-structured interview, group discussions, participatory observations and informal conversations in the study by Dierickx et al (2018).
In eight of the chosen articles, the interviews were recorded and transcribed verbatim (Behboodi-Moghadam et al., 2012; Batool &de Visser, 2012; Boz & Okumus, 2017; Dierickx et al, 2018; Daibes et al., 2017; Fledderjohann, 2012; Nguimfack et al., 2017; Tiu
et al., 2018). In the study of Cunningham & Cunningham (2013), the authors collected
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4. Discussion
4.1 Main results
This review described the women’ s experiences of infertility. Four themes were derived from the results: 1) Pressure from family; 2) Suffering violence; 3) Emotional expressions; 4) Coping strategies. The infertile women experienced pressure from family, not only from husbands but also from relatives. They suffered violence, including physical abuse and psychological abuse. Facing infertility, these women expressed their social isolation, stigma, lacking of control, depression and stress. Certainly, they also adopted coping strategies.
4.2 Results discussion
4.2.1 Pressure from family
Women who had experienced infertility would be under pressure from family, they got pressure from husbands and their relatives (Daibes et al., 2017; Dierickx et al., 2018; Batool & de Visser, 2012; Cunningham & Cunningham, 2013; Behboodi-Moghadam et al., 2012; Fledderjohann, 2012; Tiu et al., 2018; Nguimfack et al., 2017). As for pressure from husbands, infertile women would experience the marital instability (Daibes et al., 2017; Dierickx et al., 2018; Batool & de Visser, 2012; Cunningham & Cunningham, 2013; Behboodi-Moghadam et al., 2012; Fledderjohann, 2012). This was consistent with the studies by Luk & Loke (2014), as they mentioned that women' s relationships with their husbands were threatened due to infertility (Luk & Loke, 2014). Thus, nurses could guide infertile women and their husbands to positive emotions, provide them with information about infertility treatment, help ease their stress, and coordinate their strained relationships (Ying
et al., 2016).
In Meleis’ s transitions theory, transitions involved changes in basic patterns of life (Schumacher & Meleis, 1994; Meleis et al., 2000). As a result of disease, infertile women' s relationships with their families were changing, and their relationships with their husbands and relatives were challenged. Their family atmosphere changed as well, tending to be no longer harmonious and but full of pressure instead. And these changes affected the transition. The changes in women' s relationships with their families, and the changes in their home environment, put them under a lot of pressure, making it harder for them to come to terms with their infertility transition.
4.2.2 Suffering Violence
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2018; Behboodi-Moghadam et al., 2012; Cunningham & Cunningham, 2013; Fledderjohann, 2012). It was similar with the study by Luk & Loke (2014). Their study showed that for infertile women, sometimes the family especially the husband, and the society were not the strength to support them against the disease, but the source of stress (Luk & Loke, 2014). Perhaps the fact that they were exposed to violent abuse by family members and social circumstances were more painful than their illness. Therefore, nurses could provide mindfulness interventions to infertile women and their husbands to make them more receptive to infertility and to reduce physical and emotional violence to women (Bai et al., 2019).
In Meleis’ s transitions theory, transitions were complex and multiple (Meleis et al., 2000). Women' s identities, relationships, and environments had all changed in response to the complex transition brought by infertility, and they had to face the pain of disease and the pressure of these changes. It was important for nurses to understand their transition. The transition results required the nurse's care.
4.2.3 Emotional expressions
Infertility often led to unpleasant emotional experiences for women and so they were emotionally vulnerable. They stayed away from and rejected social activities, and experienced social isolation (Boz & Okumus, 2017; Yao et al., 2017; Daibes et al., 2017; Tiu
et al., 2018; Batool & de Visser, 2012; Cunningham & Cunningham, 2013;
Behboodi-Moghadam et al., 2012; Fledderjohann, 2012). It was in line with the result in the study of Luk & Loke (2014). Infertile women were socially isolated, which greatly induced their depression and anxiety (Luk & Loke, 2014). Therefore, as nurses, we should help these women develop a positive attitude towards life, accept the fact of infertility, and participate in some open social activities (Bai et al., 2019).
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In Meleis’ s transitions theory, transition experience could let a person to face some potential problems and damage, and could sometimes cause one’s vulnerability (Meleis et al., 2000). Faced with the transitional experience of not being able to have children, most women were overwhelmed mentally, and were often plagued by negative emotions and under great pressure in their hearts. Psychological problems were common to them, and their psychology was often vulnerable. Nurses should know that psychological care is very important to them and pay close attention to their psychological changes.
4.2.4 Coping strategies
Infertility was a very serious problem for women. Different women had different coping strategies, some women chose to cope with them in an active way while others choose to deal with them negatively.
For the active coping, this review found that some infertile women strove to find positive meaning in their lives, enrich their lives, and actively seek therapy to change their state (Daibes et al., 2017; Tiu et al., 2018; Nguimfack et al., 2017; Batool & de Visser, 2012). This finding was similar with the study by Romeiro et al (2017), which showed that positive coping strategies such as maintaining hope or accepting the truth could adapt and even transcend the pain (Romeiro et al., 2017). Therefore, nurses should guide infertile women to find the positive meaning and beauty of life, and thus developing an open or accepting attitude (Bai et al., 2019).
For the negative coping, some women chose passive avoidance in the face of infertility, giving up in the face of religion and treatment (Batool & de Visser, 2012; Cunningham & Cunningham, 2013). As for religion, they blamed god and thought it was unfair for them (Batool & de Visser, 2012). Consistent with the study of Ying et al (2015), this study found that infertile women tended to have negative coping strategies, and avoidance and complaining were often their choices (Ying et al., 2015). In Meleis’ s transitions theory, the nurse played an important role for clients and their families who were undergoing transitions (Schumacher & Meleis, 1994; Meleis et al., 2000). Therefore, nurses should be aware of their negative thoughts or behaviors, patiently explain to them the medical knowledge and treatment plan of the disease, encourage patients to seek information about the physiological conditions related to infertility, and could also provide such information when they were able (Wiehe, 1976).
4.3 Methods discussion
15
which had a certain degree of credibility. Second, the authors searched two different databases, PubMed and CINAHL, which improved the credibility and scientific nature of the results. Moreover, the authors also used other free text search to obtain more results related to the purpose of this study, which enriched the results of this study. Finally, the articles cited in the results of this review were qualitative articles, which were beneficial for studying the experiences of infertile women (Polit & Beck, 2017).
However, there were some limitations as well. First, the authors read the titles and abstracts to select and exclude relevant articles, as a result, some of these articles would be missed. Even if the title and abstract of an article did not meet the aim of the study, its contents may be applicable. Second, the authors only used two databases for retrieval, and only 10 articles were selected. The sample size was small, and the research results were not comprehensive. Third, the selected articles were 10-year studies which included only relevant contents of the recent period, lacking of previous studies and persistence. As a result, the results of the review may not convince everyone.
4.4 Clinical implication for nursing
The results of this review presented the experiences of infertile women and the importance of nurses having knowledge about the experiences of infertile women. Infertility put great pressure on women, subjecting them to physical and emotional violence, and immersing them in negative emotions. Understanding the experiences of infertile women could help nurses better understand their feelings and provide them with better nursing care. In nursing practices, nurses could effectively relieve women' s family stress, help them avoid violence, provide them with specialized psychological care, and guide them to cope with the disease. Currently, this review could provide nurses with some knowledge about the experiences of infertile women, help them to gain more knowledge about the impact of infertility and better promote the health of infertile women.
4.5 Suggestions for further research
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5. Conclusions
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6. Reference
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Behboodi-Moghadam Z., Mahvash S., Eftekhar-Ardabily H., Vaismoradi M., & Ramezanzadeh F. (2012). Experiences of infertility through the lens of Iranian infertile women: A qualitative study. Japan Journal of Nursing Science. 10(1), 41–46. DOI:10.1111/j.1742-7924.2012.00208. x.
Berardis D. D., Mazza M., Marini S., Nibletto L. D., Serroni N., Pino M. C., Valchera A., Ortolani C., Ciarrocchi F., Martinotti G., & Giannantonio M. D. (2014). Psychopathology, emotional aspects and psychological counselling in infertility: a review. Clinica Terapeutica, 165(3). DOI: 10.7417/CT.2014.1716.
Borght M. V., & Wyns C. (2018). Fertility and infertility: Definition and epidemiology.
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APPENDIX 1
Overview of selected articles
Author(s)
+year/country of publication
Title Design(possibly approach)
Participants Data collection method(s) Data analysis method(s) Codes Behboodi-Moghadam Z. Mahvash S. Eftekhar-Ardabily H. Vaismoradi M. Ramezanzadeh F. 2012+Japan Experiences of infertility through the lens of Iranian infertile women: A qualitative study A descriptive design A qualitative approach Number: 10
Age: 25-45 years old Education: Two
participants had an academic degree, two had secondary education, and six had incomplete secondary education. Semi-structured interviews. Length of interview: 45-90minutes. Interviews were recorded and transcribed verbatim. (Graneheim & Landman 2004) A Batool S. S. de Visser R. O. 2012+UK Experiences of Infertility in British and Pakistani Women: A Cross-Cultural Qualitative Analysis A descriptive design A qualitative approach
Number: 14(UK sample
consisted of eight women, the Pakistan sample consisted of six women)
Age:
UK(30-46)
Pakistan (24-42) years old
Semi-structured interviews. Length of interview:50–90 minutes Interviews were recorded and Idiographic case- study approach( de Visser & Smith, 2006)
23
Education: from secondary
school to postgraduate degrees transcribed verbatim. Boz I˙ . Okumus Hu¨lya. 2017+Taiwan The ‘‘Everything About the Existence’’ Experiences of Turkish Women With Infertility: Solicited Diaries in Qualitative Research A descriptive design A qualitative approach Number: 18
Age :18- 45 years old;
Diary entries. Length of interview: over an 8-month period between April and November 2013 Records of the collection information Thematic analysis C Cunningham N. Cunningham T. 2013+UK Women’ s experiences with infertility -towards a relational model of care A descriptive design A qualitative approach Number: 9
Age: 28-44 years old
Asynchronous online life-story interviews. Length of interviews: a minimum completion time of 12 days and maximum completion time of five weeks.
Online literacy and technical ease
Voice-centered relational analysis (Brown
& Gilligan 1991, Mauthner & Doucet 1998)
24 Dierickx S. Rahbari L. Longman C. Jaiteh F. Coene G. 2018+Belgium ‘I am always crying on the inside’: a qualitative study on the implications of infertility on women’s lives in urban Gambia A descriptive design A qualitative approach Number:33 Age: Adult Semi-structured interview, group discussions, participatory observations and informal conversations Length of interview: 1 hour Interviews were recorded
Both process and thematic content analysis. E Daibes M. A. Safadi R. R. Athamneh T. Anees I. F. Constantino R. E. 2017 +UK ‘Half a woman, half a man; that is how they make me feel’: a qualitative study of rural Jordanian women’s experience of infertility A descriptive design A qualitative approach Number: 14
25 Fledderjohann
J. J. 2012+UK
‘Zero is not good for me’: implications of infertility in Ghana A descriptive design A qualitative approach Number: 107
Age:21-48 years old; Mean age:33 years old;
26 Tiu M. M. H. Hong J. Y. F. Cheng V. C. Kam C. Y. C. Ng B. T. Y. 2018+Hong Kong Lived experience of infertility among Hong Kong Chinese women A explorative design A qualitative approach Number: 13
Age: 34 -52 years old;
duration of marriage (years): 4 - 22 years
In-depth, semi-structured interview Length of interview: 1 hour
Take notes together with tape-recording Thematic analysis I Yao H. Hoi C. Chan Y. Lai C. Chan W. 2018+Hong Kong Childbearing importance: A qualitative study of women with infertility in China A descriptive design A qualitative approach Number: 15 Age :20 to 45 Semi-structured interview Length of interview:60–90 minutes audio-recorded with permission and then transcribed verbatim for analysis.
27
APPENDIX 2
Author(s) Aim Results
Behboodi-Moghadam Z. Mahvash S.
Eftekhar-Ardabily H. Vaismoradi M. Ramezanzadeh F.
To explore and describe the experiences of Iranian infertile women regarding infertility
A1: Psychological abuse: humiliate
A2: Physical abuse: physical violence(beat) A3: Marital instability: increased, the distance
between the couples broadened, got divorce(finds another woman)
A4: Social isolation: did not like to participate in social activities and preferred to be alone A5: Loss of self-esteem
Batool S. S. de Visser R. O.
To explore the experiences of infertile women in two different cultures.
B1: Anxiety and depression
B2: Felt a negative impact of infertility on their physical/sexual relationship
B3: Feel stigmatized B4: Sense of isolation B5: Active avoidance;
B6: Meaning-based coping (e.g., being grateful for not being in a worse situation)
B7: Passive avoidance
B8: Religious coping (praying, recitation of the Quran)
B9: Blaming god Boz I˙ .
Okumus Hulya.
The aims of this study are to investigate the infertility experiences of women using
Watson’s Theory of Human Caring as a guide and to sensitize health-care professionals to the importance of the personal stories of these women.
C1: Losing control of everything C2: Living with the unknown
28 Cunningham N.
Cunningham T.
To consider the effectiveness of current models of patient-centered infertility care
D1: Pressure from others and expectations of having children
D2: Lack of control D3: Increasing anxiety D4: Isolation
D5: Withdrawal
D6: A sense of failure and inadequacy
D7: The impact on their close relationships: finds another woman Dierickx S. Rahbari L. Longman C. Jaiteh F. Coene G.
To explore the implications of infertility on
women’ s lives in urban Gambia E1: Financial problems’ impact on their daily lives.
E2: Differential social experiences depending on women’s position: lower socioeconomic background were more likely to be harshly confronted with the social stigma of infertility E3: Stigmatization within the community: gossips,
jokes and rumors
E4: The tensions in the relationship between women with infertility and their family-in-law E5: Physical violence
E6: Fears of divorce, extramarital relationships, polygyny
E7: Emotional impact of infertility: under stress ; felt desperate ; depression
Daibes M. A. Safadi R. R. Athamneh T. Anees I. F. Constantino R. E.
This study aimed to explore responses to infertility and its consequences in the Jordanian rural sociocultural context.
F1: Feelings of submission and subjugation to their husbands to avoid being reminded of their infertility, provoking or losing their husband, or receiving verbal abuse.
29 woman bear, the higher her status will be in her family-in-law.
F3: Self-isolation: cut themselves off from social events
F4: Internalizing the negative views of others towards themselves
F5: Seeking natural and medical sources of treatment
F6: The influence of family-in-law on the husband’s attitude
F7: Stigma
F8: Being viewed negatively by other women: perceived as being ‘evil’ and ‘envious’ of them and their children
F9: Placed under the gaze and surveillance of others
Fledderjohann J. J. To explore the implications
of infertility for Ghanaian women.
G1: Mental health: depression, worrying about difficulties, sadness and loneliness, stress G2: Domestic violence
G3: Polygyny or divorce
G4: Social interactions: mocking, insults G5: Duplicitous friendships and ostracism
G6: The responsibility for infertility is often borne by women
Nguimfack L. Newsom K. Nguekeu M. R.
The authors of this case study explored the cultural-bound experience of infertility for a Cameroonian woman.
H1: Stress within the Couple Relationship H2: Loss of Respect from Extended Family H3: Viewed as a Failure by Biological Parents H4: Not Giving Up and Having Faith
30 Tiu M. M. H. Hong J. Y. F. Cheng V. C. Kam C. Y. C. Ng B. T. Y.
This study aims to explore and describe the phenomenon of women with infertility and to enhance understanding on how infertility affects their lives and the specific social consequence they encountered.
I1: Family-in-law can be dissatisfied
I2: Psychological distress: isolation caused by envy;
I3: Disappointment towards the reproductive health services;
I4: Self-compassion as coping strategies I5: Religion as coping strategies
Yao H. Hoi C. Chan Y. Lai C. Chan W.
The primary goal of this study was to examine and describe the importance of childbearing as perceived by infertile women in the Chinese familial and social context.
J1: Love and affection between couples become more diluted, marital instability threatens marital bonds.
31
APPENDIX 3
Theme Categories Findings
Pressure from family Pressure from husbands A3: Marital instability: increased and the
distance between the couples broadened and got divorce (finds another woman) B2: Felt a negative impact of infertility on their
physical/sexual relationships
D7: The impact on their close relationships: finds another woman
E6: Fears of a divorce, extramarital relationships, polygyny
F1: Feelings of submission and subjugation to their husbands to avoid being reminded of their infertility, provoking or losing their husband, or receiving verbal abuse. G3: Polygyny or divorce
J1: Love and affection between couples become more diluted, marital instability and threaten marital bonds.
Pressure from relatives E4: The tensions in the relationship between women with infertility and their family-in-law
32 F6: The influence of family-in-law on the
husband’s attitude
H3: Viewed as a Failure by Biological Parents I1: Family-in-law can be dissatisfied
Suffering Violence Physical abuse A2: Physical abuse: physical violence(beat)
E5: Physical violence G2: Domestic violence
Psychological abuse A1: Psychological abuse: humiliate
D1: Pressure from others and expectations of having children
F8: Being viewed negatively by other women: perceived as being ‘evil’ and ‘envious’ of them and their children
F9: Placed under the gaze and surveillance of others
G4: Social interactions: mocking, insults G6: The responsibility for infertility is often
borne by women
Emotional expressions Social isolation A4: Social isolation: did not like to participate
in social activities and preferred to be alone
B4: Sense of isolation
C3: Alienation from the fertile world D4: Isolation
33 G5: Duplicitous friendships and ostracism I2: Psychological distress: isolation caused by
envy
J2: In a sense of isolation, dodge interpersonal gatherings
Stigma B3: Feel stigmatized
E2: Differential social experiences depending on women’s position: lower
socioeconomic background were more likely to be harshly confronted with the social stigma of infertility
E3: Stigmatization within the community: gossips, jokes and rumors
Lack of control C1: Losing control of everything
C2: Living with the unknown D2: Lack of control
Depression & Stress A5: Loss of self-esteem
B1: Anxiety and depression D3: Increasing anxiety
D6: A sense of failure and inadequacy E7: Emotional impact of infertility: under
stress; felt desperate; depression
34 H5: Empathetic towards her husband: can't
bear a child for him
Coping strategies Active coping B5: Active avoidance
B6: Meaning-based coping (e.g., being grateful for not being in a worse situation)
B8: Religious coping (praying, recitation of the Quran)
F5: Seeking natural and medical sources of treatment
H4: Not Giving Up and Having Faith
I4: Transferred the crisis to a positive attitude I5: Religion as coping strategies
Negative coping B7: Passive avoidance
