1

Lived Experience of Couples undergoing Infertility Treatment at N

Superspeciality Hospital, Adoor

A Dissertation submitted to the University of Kerala in partial fulfillment of requirements for the

Master of Social Work Degree Examination

SUBMITTED BY

Name : Riya K. Aniyan

Exam Code : 91518401

Candidate Code : 91518115020

Subject Code : SW 2.4.5

DEPARTMENT OF SOCIAL WORK

LOYOLA COLLEGE OF SOCIAL SCIENCES

SREEKARIYAM, THIRUVANANTHAPURAM

UNIVERSITY OF KERALA

2018-2020

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CERTIFICATE OF APPROVAL

This is to certify that this dissertation is a record of genuine work done by Ms. Riya K. Aniyan,

Master of Social Work Semester-4 student of this College under any super vision and guidance

and that it is hereby approved for submission.

Ms. Vandana Suresh

Research Guide

Department of Social Work

Loyola College of Social Sciences

Sreekariyam, Thiruvananthapuram

Recommended for forwarding to the University of Kerala

Dr. Sonny Jose

Head, Department of Social Work

Loyola College of Social Sciences

Sreekariyam, Thiruvananthapuram

Forwarded to the University of Kerala

Dr. Saji P Jacob

Principal

Loyola College of Social Sciences

Sreekariyam, Thiruvananthapuram

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DECLARATION

I, Riya K. Aniyan do here by declare that the Dissertation Titled “Lived Experience of Couples

undergoing Infertility Treatment at N Superspeciality Hospital, Adoor” is based on the

original work carried out by me and submitted to the University of Kerala during the year 2018-

2020 towards partial fulfillment of the requirements for the Master of Social Work Degree

Examination. It has not been submitted for the award of any degree, diploma, fellowship or other

similar title of recognition before.

Sreekariyam Ms. Riya K. Aniyan

03/08/2020

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ACKNOWLEDGEMENT

Fore mostly I extend profound thanks to Almighty God who has blessed me the opportunities and

intellectual ability to complete my research successfully.

I was lucky to have Ms. Vandana Suresh, Lecturer of the Department of Social Work, Loyola

College of Social Sciences as my guide. She was the leading spirit in my endeavour; she had

motivated me in my times of my confusion, stood for me, with me. At this juncture I extend my

heartfelt respect and gratitude for all the pain that she had taken for the completion of my study.

I extend my heartfelt gratitude to Dr. Saji. P. Jacob, Principal Loyola College of Social Sciences

and Dr. Sonny Jose, Head of the Social Work Department, Fr. Sabu P. Thomas S.J., Ms.

Francina P.X. and Fr.Saji Joseph S.J. and Dr. Jasmine Alexander., faculty Members

Department of Social Work for their help on various occasions during the course of this work.

I express my sincere thanks to Dr. Sunil Kumar, Librarian and Mr. George Mathew, Assistant

Librarian, Loyola College of Social Sciences for providing necessary reference materials, and

their kind support for the successful completion of my work so far.

I express my sincere gratitude to all the respondents who have participated in the process of my

data collection.

It would not have been possible for me to successfully complete this work without the constant

encouragement and support of my beloved family.

I could never conclude this without mentioning my dearest friends, whose whole hearted support

made me to present this before you.

RIYA K. ANIYAN

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CONTENTS

S. No Chapters Page Number

1 Introduction 8-22

2 Literature Review 23-38

3 Methodology 39-44

4 Case Description / Narratives 45-62

5 Thematic Analysis and

Discussion

63-85

6 Findings, Suggestions and

Conclusions

86-92

7 Reference and Appendixes 93-100

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LIST OF TABLES

Sl. No Title of the Table Page Number

1 Profile of the Cases 64

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ABSTRACT

Infertility ―is a disease of the reproductive system defined by the failure to achieve a

clinical pregnancy after 12 months or more of regular unprotected sexual intercourse (WHO,

2020). Infertility not only affects a person and her/his family life, but also his physical,

mental, psychological and social well-being. Most couples diagnosed with infertility opt for

fertility treatment to materialize their dream of having a child of their own. This qualitative

study aims to understand the lived experience of couples undergoing treatment for infertility

at X Super- speciality Hospital, Adoor. Data was collected from 3 couples undergoing

treatment for infertility for more than two years. The samples were purposively selected and

interviewed using a semi-structured interview guide. Multiple case study design was adopted

and thematic analysis was done to analyze the data. The findings of the study indicate that the

couples experienced stress, anxiety, fear, frustration and feeling of guilt of not being able to

birth an offspring. The initial reaction of the couples to the news of infertility was shock and

unbearable sadness, as they knew that they have to undergo long-term and very expensive

treatment in the future. It was noticed that their families support helped them throughout their

ordeal. The couple encountered challenges - physical, psychological and social, before

undergoing the treatment. Not being able to embrace parenthood even after several years of

married life caused frustration and emotional distress in couples. The female partners faced

more difficulty in socialization, when compared to the males as they felt that the society

would amplify on their inability to conceive a child for their own fault. Constant pressure

from their family and friends to undergo treatment, coupled with questions from others,

forced the respondents to undergo infertility treatment for. The experience shared by other

couples with similar problem also motivated them to seek treatment. Various coping

strategies - confronting or avoiding reality, mutually support, and ventilation of feelings to

their spouse, family and friends - were adopted by the couples, individually and together to

helped them tide this phase.

KEY WORDS: Couples with infertility, Challenges, Coping strategy

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CHAPTER 1

INTRODUCTION

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1.1 INTRODUCTION

India is the second most populous country of the world after China. Population of India is

projected close to be 1.38 billion or 1,380 million in 2020. There are 71.7 crore males and

66.3 crore females living in India. Although India accounts for a meager 2.4 percent of the

world surface area yet it supports and sustains a whopping 17.8 percent of the world

population. It is now estimated that by 2027, India will most likely overtake China to become

the most populous country on the earth with 1.47 billion people (Statistics Times, 2020).

Nevertheless India, the world„s second most populous nation, and Asia„s third largest

economy is facing a dramatic decline in its fertility rate. While this may be welcome news for

the overpopulated nation, it also points to the disconcerting trend of young couples unable to

procreate. According to the Indian Society of Assisted Reproduction, infertility currently

affects about 10 to 14 percent of the Indian population, with higher rates in urban areas where

one out of six couples is impacted. Nearly 27.5 million couples actively trying to conceive

suffer from infertility in India (Lal, 2018).

Infertility is ―is a disease of the reproductive system defined by the failure to achieve a

clinical pregnancy after 12 months or more of regular unprotected sexual intercourse (WHO,

2020).

„The World Population Prospects: The 2017 Revision‟ report estimates that the fertility rate

of Indians (measured as the number of children born to a woman), has plummeted by more

than 50 percent, from 4.97 during the 1975-80 period to 2.3 for the current period of 2015-20.

By 2025- 30, the report projects, the rate will nosedive further to 2.1, touching 1.86 from

2045-50 and 1.78 from 2095-2100. A fertility rate of about 2.2 is generally considered the

replacement level, the rate at which the population would hold steady. When the fertility rate

dips below this number, the population is expected to decline (Lal, 2018). Infertility and

subfertility affect a significant proportion of humanity. WHO has calculated that over 10% of

women are inflicted - women who have tried unsuccessfully, and have remained in a stable

relationship for five years or more. Estimates in women using a two year time frame, result in

prevalence values 2.5 times larger. The burden in men is unknown. The overall burden of

subfertility/infertility is significant, likely underestimated, and has not displayed any decrease

over the last 20 years (World Health Organization, 2020).

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1.2 BACKGROUND

A. INFERTILITY

Infertility is a disease of the reproductive system defined by the failure to achieve a clinical

pregnancy after 12 months or more of regular unprotected sexual intercourse (WHO, 2020).

Infertility affects up to 15% of reproductive-aged couples worldwide. According to World

Health Organization estimate the overall prevalence of primary infertility in India is between

3.9 to 16.8%. In Indian states prevalence of infertility varies from state to state such as 3.7

per cent in Uttar Pradesh, Himachal Pradesh and Maharashtra, to 5 per cent in Andhra

Pradesh, and 15 per cent in Kashmir and prevalence varies in same region across tribes and

caste (Zahid, 2016). Infertility affects an estimated 15% of couples globally, amounting to

48.5 million couples. Males are found to be solely responsible for 20-30% of infertility cases

and contribute to 50% of cases overall (Agarwal, 2015).

The word infertile means barren, unproductive and sterile. Infertility could be due to an issue

with either one or both the partners. These issues might include low hormones, inability to

ovulate in women, low sperm count in men and so on. Infertility not only affects a person and

his family life but also his physical, mental, psychological and social well-being. Thought of

childlessness happens mostly by the time it„s too late to take normal medication to try in slow

pace. Even though there are several options in treatment when it comes to infertility, adoption

would only be the last of all as having a child genetically related to the parents is of great

priority for all. Fertility treatments are very commonly practiced all over the world now. But

the psychosocial consequences that the couples face during these treatments and this phase of

their life is a topic of discussion, especially in today„s time when mental health needs to be

addressed more than anything. Adoption continues to remain an undesirable option because

the links between an adopted child and the social parent become a public, vocal, and visible

admission of infertility that cannot be subsumed (Bharadwaj, 2003).

The news of infertility is usually unexpected for most of the couples. It might happen when

they want nothing more but to become parents after the so called gap they have taken to settle

in life. And thus accepting their situation might become time and money consuming as most

of them go for second opinions. There are several options like Artificial Insemination,

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surrogacy, adoption and so on, but having a child genetically related to the parents will

always be in the top of their priority list. Fertility treatments like IVF could have several

effects on their physical, mental and social health. Financial burden can also be exhausting.

There has been a major acceptance among the public regarding fertility issues lately. Before

several years it was the woman who was always responsible for being barren and cannot bear

a child. But now, the emergence of effective treatment methods in medical field has paved

way to intense study regarding the exact reason behind the all condition that demands

treatment. Infertility can be of several types and can occur due to many reasons.

CAUSES OF INFERTILITY

About one quarter of infertility cases in women are due to ovulation disorders. If a woman

has an ovulation disorder, she may ovulate infrequently or not all. Polycystic Ovarian

Syndrome (PCOS) is one of the most common disorders impacting ovulation. Infertility due

to age is one of the most common causes of female infertility. Tubal factor fertility,

Endometriosis, Endometrial polyps and uterine polyps are some other causes.

In men, Varicocele, Ejaculation disorders, Cancers and nonmalignant tumors, Undescended

testicles, Sperm Transport Issues, Celiac disease, Low sperm counts are some of the causes of

infertility in men. Other than this there might be genetic disorders that act the causes too

(CCRM Fertility, 2019).

TYPES OF INFERTILITY

There are two types of infertility; primary infertility and secondary infertility.

Primary infertility refers to couples who have not become pregnant after at least 1 year

having sex without using birth control methods. This is the most common situation where

treatment is usually taken.

Secondary infertility refers to couples who have been able to get pregnant at least once, but

now is unable. The parents might not get conceived due to Female Infertility, Male Infertility

or both together.

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1 Female Infertility can happen if a fertilized egg or embryo does not survive once it

gets attached to the uterine wall, when the uterine wall fails to hold the fertilized egg,

if the motility of the egg is restricted from ovaries to the womb and when production

of eggs in the ovaries is disturbed. Ovarian cysts and Polycystic Ovary Syndrome

(PCOS) is one of the most common reasons behind infertility among women. Pelvic

infection resulting in scarring or swelling of fallopian tubes (hydrosalpinx) or Pelvic

Inflammatory Disease (PID) is the other reasons.

2 Male Infertility may be due to low sperm count, blockage in sperm tract that prevent

sperm from being released during sexual intercourse and sperm defects. Exposure to

high heat for prolonged period of time can affect sperm production processes, causing

the body to produce fewer sperm, many of which may be abnormally shaped.

Retrograde ejaculation and Vasectomy or failures of Vasectomy Reversa are two

other reasons.

There are issues that happen to both males and females at the same time. Thus infertility

could happen also due to other reasons like Autoimmune disorders, such as Anti

Phospholipid Syndrome (APS), birth defects that affect the reproductive tract, other medical

conditions like any cancer or tumor, diabetes, eating disorders or poor nutrition, growths in

the reproductive organ, reaction to medicines such as chemotherapy drugs, hormone

imbalance, infections, obesity, older age, scarring from sexually transmitted infections

(STIs), injury, smoking, heavy use of alcohol and thyroid disease (MedlinePLus, 2020).

B. ISSUES FACED BY INFERTILE COUPLES

The consequences of infertility in developing countries range from severe economic

deprivation, to social isolation, to murder and suicide. Disproportionately having an effect on

women, the burden of disease of infertility is often assumed to be the fault of the woman, as

pregnancy and child birth are manifested in the woman. Yet, the male reproductive capacity

was found to be deficient in not less than 50% of infertile couples.

An inability to have a child or to become pregnant can result in being greatly ostracized;

feared or shunned; may be used as grounds for divorce; may result in a mental disorder; can

lead to suicide; and will often justify a denial to take part in family or community traditions.

In some societies, discrimination in the case of the female may take a form of denial of

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passage to adulthood: a girl will not pass into womanhood (regardless of age) if she cannot

prove her fertility. This girl may no longer be considered marriageable and may become

viewed as a burden on families, communities or societies (Petitpierre, 2020).

For both partners, infertility is a complex and situational crisis that is generically

psychologically threatening, emotionally stressful, financially challenging, and physically

painful most of the times due to diagnostic-curative operations undergone. Infertility triggers

a range of physical, psychological, social, emotional, and financial effects. Although it is not

a life-threatening problem, infertility is yet experienced as a stressful life event for couples or

individuals due to the exalted value attributed to having a child by individuals themselves or

society in general. Infertile couples are not facing a medical condition alone but coping with a

number of emotional states as well. Emotions, thoughts, and beliefs of infertile couples

frequently change as one consequence of infertility diagnosis. Exposed to a tremendous

social pressure, infertile couples may resort to hiding the problem due to the extreme privacy

of the matter. Infertility also affects marriage life adversely (Hocaoglu, 2018).

C. TREATMENTS FOR INFERTILITY

History

The documents discussing gynecological disorders could be traced back to 1900BC Egyptian

society. Male and female infertility was given equal importance by them. Infertility and its

treatment was to a great extend related to religion as Priests were the physicians and

medicines were permeated with magic. Examinations were based on the concept that the

genital organs were in continuity with the rest of the body and, in particular, with the

digestive system. This way of thinking remained in place for hundreds of years and was

adopted by Hippocrates and many medieval physicians. Knowledge about Jewish medicine

on infertility could be received through Bible. It shows that women were bound to be fruitful

and replenish, giving them no other rights and liberties. Pregnancy was considered a gift from

God and children conceived by the will of God were to be his servants.

Greece was the source of Western medicine. Hippocrates and his school developed a system

of medical reasoning based on rational thinking and avoided the element of magic in

medicine. The role of the Gods was just as important during the Roman era. During the feast

for Mars, the priests to this god would run through the city whipping the bellies of infertile

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women with a goatskin whip. Many Roman physicians believed that conception took place

right after menstruation. The period prior to menstruation was infertile because the uterus was

overloaded. Galien (130-200 AD), believed that the phases of the moon had an effect on the

feminine cycle. There were little advancements in the treatment of infertility during Roman

times.

There were undeniable scientific progress and advancements in modern day thinking and

treatment of infertility during the Renaissance period. Da Vince and others made studies as

the mysteries of the female body were gradually resolved and scientific thinking and

reasoning replaced magic and the gods. In 1562, Bartolomeo recommended that husbands

should put their finger in the vagina after intercourse to encourage conception. This was the

ancestor of the idea of artificial insemination. The one to carry out experiments and describe

the fertilization process first was Smellie. Despite the progress that was made during these

times, infertility was almost synonymous with the female; and it was rare that the husband

was considered as a cause. Even during this age of enlightenment, a real ambiguity existed.

Women became the source of continual interest but were considered weak and sensitive

(Morice et al., 1995).

The nineteenth and twentieth centuries were marked by tremendous advances in the diagnosis

and treatment of infertility. In 1898, fertilization was described as the union of an egg and a

sperm. 80 years later, the first ―test-tube‖ baby was born in England and in 1981, her in-vitro

sister was born. The first IVF baby born in the US was in 1981, pioneered by fertility

specialists at Eastern Virginia Medical School in Norfolk, Virginia. Since those early days, a

little more than 25 years ago, tremendous progress has been made in the understanding,

diagnosis and successful treatment of so many of the causes of infertility. And step by slow

step, infertile women have come to be considered patients in her own right, instead of a

curiosity and condemned member of the human society, living in silence and

misunderstanding; no longer being considered witches and burned at the stake, but replaced

as the centre of medical and scientific attention, and possibly lying at the very source of all

human survival (Arizona Center for Fertility Studies, 2015).

TYPES FOR TREATMENTS FOR INFERTILITY

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Fertility can be sometimes restored in women through the intake of ovulation stimulating

hormones, if that is the case. Clomiphene citrate, Gonadotropins, Metformin, Letrozole,

Bromocriptine are some of the examples. Laparoscopic or hysteroscopic surgery and Tubal

surgeries also helps to restore fertility. When all these, in some way is not possible the

couples undergo other methods of infertility treatments called Artificial Reproductive

Technology (ART). Intra Uterine Insemination (IUI) is the most commonly practiced

method among Artificial Insemination (AI) for woman when the male sperms are not strong

enough to swim through the cervix up into the fallopian tube. When the issue is female

infertility, it is sometimes done if one has a condition called endometriosis or any

abnormality for the reproductive organs (WebMD, n.d).

Zygote Intrafallopian Transfer (ZIFT): A technique in which a woman's egg is fertilized

outside the body, then implanted in one of her fallopian tubes. This technique is one of the

methods used to overcome infertility, the inability of couples to produce offspring on their

own. First, the egg and the male sperm needed to fertilize it are harvested. Then the egg and

the sperm are united in a petri dish, a multi-purpose glass or plastic container with a lid. If all

goes well, the sperm fertilizes the egg, and the physicians then implant it in a fallopian tube.

From there, nature takes its course, and the egg eventually is deposited by the fallopian tube

into the uterus (womb) for development.

Gamete intrafallopian transfer (GIFT) uses multiple eggs collected from the ovaries. The

eggs are placed into a thin flexible tube (catheter) along with the sperm to be used. The

gametes (both eggs and sperm) are then injected into the fallopian tubes using a surgical

procedure called laparoscopy. The doctor will use general anesthesia. Pronuclear stage

tubal transfer (PROST), similar to ZIFT, uses in vitro fertilization. But it transfers the

fertilized egg to the fallopian tube before cell division occurs. These procedures have higher

costs and risks related to laparoscopy. And they do not provide as much useful information

about embryo development as IVF does (Michigan Medicine, 2018).

IVF stands for In Vitro Fertilization. It is one of the more widely known types of assisted

reproductive technology (ART). IVF works by using a combination of medicines and surgical

procedures to help sperm fertilize an egg, and help the fertilized egg implant into the uterus.

At first medication is taken to produce several of the eggs. After it gets matured and ready for

fertilization, the doctor takes the eggs out of the woman„s body and mixes them with sperm

in a lab, to help the sperm fertilize the eggs. Then they put 1 or more fertilized eggs

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(embryos) directly into the uterus. Pregnancy happens if any of the embryos implant in the

lining of your uterus. IVF has many steps, and it takes several months to complete the whole

process. It sometimes works on the first try, but many people need more than one round of

IVF to get pregnant. IVF is done when the mother has Fallopian tube damage or blockage,

ovulation disorders, endometriosis, uterine fibroids, previous tubal sterilization or removal

and if the father has low sperm count or motility. It is also used anticipating genetic disorders,

fertility preservation for cancer and other health conditions and so on. Intra-Cytoplasmic

Sperm Injection (ICSI) is another method where a single sperm is injected through a tiny

needle into an egg. The fertilized egg is then implanted in the uterus. ICSI can be performed

when sperm counts are extremely low or abnormal (Martel, 2016).

The ultimate goal of male infertility treatment is to create a pregnancy. Ideally, the cause of

the infertility is reversible and then conception can result from natural sex. In men

Varicoceles are repaired with surgery to block off the abnormal veins. This seems to result in

a significant improvement in fertility, although some studies disagree. Hormonal

abnormalities can sometimes be treated with medicine or surgery. Obstructions in the sperm

transport plumbing can sometimes be surgically corrected. These high-tech and expensive

male infertility treatments give sperm an artificial boost to get into an egg. ARTs have made

conception possible even for men with very low or abnormal sperm. Treatments like IVF and

ICSI are used in female body when sperm count is low or abnormal in the male partner.

RISKS OF INFERTILITY TREATMENTS

Drugs: Pregnancy with multiples is a risk even though it is fairly low in chance (less than 10

percent) but mostly with the risk of twins. The chances increase up to 30 percent with

injectable medications. Injectable fertility medications also carry the major risk of triplets or

more (higher order multiple pregnancy). Generally, the more foetuses one is carrying, the

greater the risk of premature labour, low birth weight and later developmental problems.

Sometimes adjusting medications can lower the risk of multiples, if too many follicles

develop.

Ovarian hyper-stimulation syndrome (OHSS); Injecting fertility drugs to induce ovulation

can cause OHSS, which causes swollen and painful ovaries. Signs and symptoms usually go

away without treatment, and include mild abdominal pain, bloating, nausea, vomiting and

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diarrhoea. Rarely, it's possible to develop a more-severe form of OHSS that can also cause

rapid weight gain, enlarged painful ovaries, fluid in the abdomen and shortness of breath,

once the person gets pregnant. Long-term risks of ovarian tumors; most studies of women

using fertility drugs suggest that there are few if any long-term risks. However, a few studies

suggest that women taking fertility drugs for 12 or more months without a successful

pregnancy may be at increased risk of borderline ovarian tumors later in life (Mayo Clinic,

n.d).

Fertility restoration surgery: Surgeries can leave behind permanent scars or tear in

fallopian tube, uterus etc. There is a possibility of the occurrence of infections, if not given

careful treatment post-surgery. This can make the situation even worse and irreversible.

Peritonitis is a life-threatening infection of the tissue covering organs in the belly (WebMD,

n.d).

Artificial Reproductive Technique (ART): The risk of conceiving twins or triplets

increases if a woman receives IUI at the same time as other fertility medication, such as

gonadotrophin. A pregnancy with more than one foetus increases the chances of

complications, such as premature birth or miscarriage. Doctors only prescribe fertility

medication when there are difficulties with ovulation, or producing the egg cells from which

an embryo develops. Ovarian hyperstimulation syndrome (OHSS) can have the ovaries to

swell after combining fertility medication and IUI. It is rare, and symptoms are usually mild-

to-moderate, but it can sometimes have serious complications. In mild cases of OHSS,

symptoms include bloating, slight abdominal pain, and possibly nausea and vomiting. More

severe cases may feature dehydration, chest pain and shortness of breath. (Paddock, 2018).

Miscarriage (pregnancy loss), ectopic pregnancy (when the eggs implant outside the uterus)

and bleeding, infection, or damage to the bowels or bladder are some other complications

related to IVF (Martel, 2016).

D. LEGAL AND ETHICAL ASPECTS OF TREATMENTS FOR

INFERTILITY

Worldwide, more than 70 million couples are afflicted with infertility. Since the first

successful IVF procedure in 1978, the use of this and related technologies has expanded to

become commonplace around the globe. Over the past decade, the use of ART services has

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increased at a rate of 5–10% annually. The widespread use of this technology throughout the

world has prompted a desire by the public, governmental bodies, and professional

organizations to create mechanisms that evaluate the utilization of ART.

Advances in the arena of assisted reproductive technologies (ART) are accompanied by

ethical and societal concerns. Legislation and professional societies have attempted to address

these concerns for some time. For example, in 1986, the American Fertility Society first

published guidelines for the ethical implementation of ART in the United States. The

dynamic nature of ART and the rapid evolution of the field result in constant paradigm shifts

that require frequent and comprehensive evaluation by professional organizations and society

alike.

In the 1980s, concerns surrounding ART focused on the safe administration of gonadotropins,

transparency of pregnancy data from clinics, and addressing economic barriers to ART

access. Some of these issues, such as reporting requirements for ART pregnancy results, have

also been mandated with legislation in many nations. Furthermore, ART reporting

requirements generally include the number of embryos transferred. This measure has been

extremely important in correlating the risk of multiple gestations with the transfer of 2 or

more embryos. However, in many nations, reporting regulations are not accompanied by

legislation defining practice patterns.

Through centralized mandatory reporting registries, general estimates of IVF activity are

available in many nations. In an effort to define current IVF statistics and to make this

information more transparent and available to patients, the Fertility Clinic Success Rate and

Certification Act of 1992 was created in the United States. This law requires clinics providing

IVF in the United States to report specific information regarding IVF cycles, including

pregnancy rates. This reporting data is only reported on IVF cycle outcomes and does not

include detailed information regarding the maternal or paternal medical history. A detailed

accounting for ART reporting and regulations across the globe is available from the

International Federation of Fertility Societies (IFFS). In their 2010 report, the IFFS reported

ART outcomes data from 59 countries.

Increasingly, nations have enacted legislation that defines the parameters for acceptable

practice of ART. The transfer of multiple embryos in a single cycle increases the rates of

multiple births. Because of the increased social costs and health risks associated with multiple

births, legislation or guidelines from professional societies have been introduced in many

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countries restricting the number of embryos that may be transferred per IVF cycle in an effort

to limit the incidence of multiple gestations.

Pre-implantation Genetic Screening (PGS) and Diagnosis (PGD) offer the unique ability to

characterize the genetic composition of embryos prior to embryo transfer. Although

controversial, using PGD to choose embryos solely on the basis of gender is currently being

practiced. Sex selection in the proper setting may offer a substantial health benefit. For

example, choosing to transfer only embryos of a certain sex may confer a therapeutic benefit

if used to avoid a known sex linked disorder (Zhao, 2012).

Indian Council of Medical Research Guidelines for gametes banks and ART Clinics

performing in vitro with donor eggs suggest that a child born through ART shall be presumed

to be the legitimate child of the couple, born within wedlock, with consent of both the

spouses, and with all the attendant rights of parentage, support and inheritance. Sperm/oocyte

donors shall have no parental right or duties in relation to the child and their anonymity shall

be protected. A child thus born will, however, be provided all information about the donor –

except from personal data as and when desired by the child, when the child becomes an adult.

No information about the treatment of couples provided under a treatment agreement may be

disclosed to anyone other than the accreditation authority or persons covered by the

registration, except with the consent of the person(s) to whom the information relates, or in a

medical emergency concerning the patient, or a court order. It is the above person„s right to

decide what information will be passed on and to whom, except in the case of a court order.

Gametes banks where a complete assessment of the donor has been done, medical and other

vital information stored, quality of preservation ensured, confidentiality assured, and strict

control exercised by a regulatory body, must be set up. Donor sperm would be made

available only through such specialized banks/centres. The information about the donor

(including a copy of the donor„s DNA fingerprint if available, but excluding information on

the name and address that is, the individual„s personal identity) should be released by the

ART clinic after appropriate identification, only to the offspring and only if asked by him/her

after he/she reaches the age of 18 years, or as and when specified and required for legal

purposes, and never to the parents (excepting when directed by a court of law).

The ART clinic must not be a party to any commercial element in donor programmes or in

gestational surrogacy. An oocyte donor cannot act as a surrogate mother for the couple to

whom the oocyte is being donated. A third-party donor and a surrogate mother must

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relinquish in writing all parental rights concerning the offspring and vice versa. Gametes

produced by a person under the age of 21 shall not be used. The accepted age for a sperm

donor shall be between 21 and 45 years and for the donor woman between 18 and 35 years.

The individual must be free of HIV and hepatitis B and C infections, hypertension, diabetes,

sexually transmitted diseases, and identifiable and common genetic disorders such as

thalassemia. The blood group and the Rh status of the individual must be determined and

placed on record.

Use of sperm donated by a relative or a known friend of either the wife or the husband shall

not be permitted. It will be the responsibility of the ART clinic to obtain sperm from

appropriate banks; neither the clinic nor the couple shall have the right to know the donor

identity and address, but both the clinic and the couple, however, shall have the right to have

the fullest possible information from the gametes bank on the donor such as height, weight,

skin colour, educational qualification, profession, family background, freedom from any

known diseases or carrier status (such as hepatitis B or AIDS), ethnic origin, and the DNA

fingerprint (if possible), before accepting the donor. The gametes bank shall not supply

semen or eggs of one donor for more than ten successful pregnancies

(EggDonationFriends.com, n.d).

1.3 STATEMENT OF THE PROBLEM

The inability to conceive a child is experienced as a stressful situation by individuals and

couples all around the world. The consequences of infertility are manifold and can include

societal repercussions and personal suffering. The medicalization of infertility has

unwittingly led to a disregard for the emotional responses that couples experience, which

include distress, loss of control, stigmatization, and a disruption in the developmental

trajectory of adulthood (M.Cousineau, 2007). Fertility attempts require tedious and expensive

medical procedures, thus, doubt and despair during treatment could threaten a couple. The

couples who have unsuccessful treatment outcomes have more emotional distress relative to

those for whom treatment had worked and females in particular indicate a lower quality of

life (Weaver, 2007).

The problem of infertility creates a ripple effect in the life of the couples, affecting the one„s

closely related to them. Such issues would affect their social life. Thus, infertility is not just

21

biological but also creates psychological, social and financial consequences. The trauma of

not being able to conceive even after several years of marriage could affect the relationship

between the couples too. According to WHO, one in every four couples in developing

countries had been found to be affected by infertility. A WHO evaluation of Demographic

and Health Surveys (DHS) data (2004), estimated that more than 186 million ever-married

women of reproductive age in developing countries were maintaining a child wish,

translating into one in every four couples.

Even after the conception of child with the help of fertility treatments, the chances of

complications during gestation period or during delivery would be high. Psychosocial

wellbeing of pregnant mother affects children‟s ability, intellectuality, productivity and social

functionality. Thus proper treatment that addresses not just the biological need but also other

aspects while undergoing treatments for infertility must be brought into attention. Though

treatments for infertility has been in practice since several years, the available literature

regarding the same does not focuses on multiple aspects or consequences of infertility in

detail. There are only a very few studies conducted in Indian context. Most of the studies are

in western context. Even among those studies more focus is given on women over their male

counterparts on dealing with the issue of infertility. This was the major research gap

identified. The present study aims to understand their lived experience of couples in dealing

with fertility treatments, giving equal importance to both counterparts.

1.4 SIGNIFICANCE OF THE STUDY

According to the Indian Society of Assisted Reproduction, infertility currently affects about

10 to 14 percent of the Indian population (Lal, 2018). In Indian society, the expectation of

attaining parenthood after marriage fosters feelings of incompleteness in the infertile couple.

Infertility has significant consequences on the marital life of the couple (Klein & Rowland

1999). Review of literature shows that most of the studies related to infertility focuses on

women as it is often though that women are most affected by infertility. In the present study

both the partners are considered. The present study aims to explore the lived experience of

couples undergoing treatment for infertility. Focus is given to understand how the issue of

infertility brings about a change in the relationship between the couples and the adaptations

they have made to overcome societal pressures attached to the inability to bear a child,

besides, the bio-psycho-social consequences of undergoing treatment for this condition. The

22

treatment requires cooperation of both the partners which stems from clear understanding

about their inability to conceive a child and the importance of undergoing treatment for a

better outcome; conception and delivery of a child. The study explores whether the couples

receive mental support from the family and friends, whether they are able to meet the

financial requirements after managing their existing needs and financial liabilities (if any).

The study also tries to understand if they are able to showcase mutual understanding and

support, if they have resources to tackle their psychological needs that arise out of infertility

issues and its treatment and also what are the coping strategies used by them throughout this

journey. The study also tries to understand the impression of the society regarding infertile

couples and treatments for infertility as perceived by the couple.

With the increase in the percentage of people seeking fertility treatment, it is important to

have a deeper understanding about the impact of undergoing treatment for infertility, not only

on their physical health but also on their psycho- social dimensions and how it affects them as

a couple. This would help in developing better intervention in future to help such couples

undergoing treatment for infertility.

23

CHAPTER 2

REVIEW OF LITERATURE

24

REVIEW OF LITERATURE

2.1 INTRODUCTION

A literature review is a comprehensive summary of previous research on a topic. The review

should enumerate, describe, summarize, objectively evaluate and clarify this previous

research. It should give a theoretical base for the research and helps the author determine the

nature of your research. The literature review acknowledges the work of previous researchers,

and in so doing, assures the reader that your work has been well conceived. It is assumed that

by mentioning a previous work in the field of study, that the author has read, evaluated, and

assimilated that work into the work at hand (Coffta, 2020). In this study, literature review is

done based on the theme with which research questions are framed. Both Indian and Western

studies are included in each category to get a better and more precise understanding about the

subject. Thus through this process, the researcher could identify the research gap.

2.2 STUDIES ON INFERTILITY

Global Perspective

Infertility has always been considered as a social stigma and has often been treated as

socially, mentally and physically damaging experience for the childless women rather than

man. Fatherhood was more a social rather than biological concept, thereby making

childlessness a legitimate ground for divorce and a matter of disgrace for women. Every

country has its own set of customs and traditional beliefs for the relief of childlessness. While

introducing a second wife was one way to overcome the predicament of childlessness,

divorce was also an available choice. There were several myths that contemplated the human

concerns and their needs during ancient times. It is evident that types of the infertility and

their treatment in the modern era have some historical background and different

representations in the ancient civilizations. One of the major causes of divorce during the

common era (c.300 CE-c.400C) was women's infertility; as mentioned in majority of the

Egyptian marriage contracts, polygamy was very common and the reason for a man opting

for more than one wife. From the medieval period to the Middle Ages (ca. 500-1500)

25

polygamous marriage was an ancient and long-standing solution to infertility in the Middle

East. Sometimes, the spouse was sought to make a temporary alliance only for the purpose of

obtaining a child from them (Radhey Shyam Sharma, 2018)

Infertility has always existed; however, today it has a different meaning because the

possibility exists, not only to treat it in some three quarters of all cases, but also, in a number

of instances, to prevent it. At the same time, this improved scenario created a number of

important new issues concerning public health policies and the social impact of infertility;

these issues can be summarized with two words: equity and ethics. Indeed, there are

intolerable differences in access to infertility care, depending on the social-economic status,

as well as the country in which a couple lives. It must be stressed that advances in assisted

reproductive technology have created not only important successes, but also significant

ethical problems: on the one hand, the debate is open on the limits of artificial interventions

in the field of reproduction; on the other the possibility exists that a partner may ''impose'' an

infertility treatment on the other (Benagiano G, 2006).

As Marcia C. Inhorn says through the study Global infertility and the globalization of new

reproductive technologies‖, infertility is a problem of global proportions, affecting on average

8 to 12 percent of couples worldwide. In some societies, however particularly those in the

infertility belt of sub-Saharan Africa as many as one-third of all couples are unable to

conceive. Factors causing high rates of tubal infertility in parts of the developing world

include sexually transmitted, postpartum, and post-abortion infections; however, male

infertility, which is rarely acknowledged, contributes to more than half of all cases.

Unfortunately, the new reproductive technologies (NRTs) such as in vitro fertilization (IVF),

which are prohibitively expensive and difficult to implement in many parts of the developing

world, represent the only solution to most cases of tubal and male infertility. Not surprisingly,

these technologies are rapidly globalizing to pronatalist developing societies, where children

are highly desired, parenthood is culturally mandatory, and childlessness socially

unacceptable (Inhorn, 2003).

E Van Balen & H M W Bos discusses about how some women wants to be childless. It is

discussed in the study titled, „Infertility, Culture, and Psychology in Worldwide Perspective‟.

The authors say that in modern individualistic societies, children are desired mainly for

individual reasons, namely, for the happiness, well-being and life fulfilment that children

bring to their parents. There are no strong constraints and social pressures on women to have

26

children. In Western societies, many women choose to be childfree. In the Netherlands, for

example, 50% of childless women in the 37-46 year-old age group declared to be childless by

choice. However, in many traditional and transitional societies, children are important for

social and financial reasons, and it is not acceptable to decide not to have children. With few

exceptions, all childless women in these societies are involuntarily childless. These mothers

suffer not only because they cannot be mothers, but also because they are isolated and

excluded from social life, subjected to scorn and slurs, loose their and suffer from poverty

and lack of support (Bos, 2004).

Indian Perspective

Infertility, over recent years, has emerged as one of the most common health issues that many

young couples have been facing. Sedentary lifestyles with minimum physical activity, rising

stress level and irregular sleep pattern are few of the reasons that, according to many

clinicians and health experts, are causing infertility, thus forcing them to opt for artificial

ways of conceiving. According to The Indian Society of Assisted Reproduction, infertility

currently affects about 10 to 14 percent of the Indian population, with higher rates in urban

areas where one out of six couples is impacted. Nearly 27.5 million couples are known to

actively trying to conceive suffer from infertility in the country. Infertility, once considered to

be a personal and surreptitious topic, is no longer applicable. Today, people discuss the same

due to their social and interpersonal ramifications. Childbearing is one of the major events in

a couple‟s life, infertility problems are now considered more seriously. It is no more

considered a health condition associated with only women. Infertility is not gender-specific

(Tyagi, 2019).

Age of women, age at first marriage, place of residence, standard of living, working status of

women, and region are some of the variables related with the rate of infertility and

childlessness. Infertility rate is high among women in urban areas. This may be due to

lifestyle or a later age at first marriage. Considering religion, Muslims show the lowest

infertility rate. Scheduled tribes have high infertility rate. With increasing levels of

educational attainment among women, infertility rate increases. This can be related to the fact

that with aspirations for attaining higher educational level, marriage is delayed as a result of

which in confirmation with aforementioned causation factors (higher age at marriage, urban

living style etc.), infertility rate is high among this sub group of population (Unisa, 2010).

27

Narendra Malhotra et al. points out in one of their studies that India has one of the highest

growths in the ART centers and the number of ART cycles performed every year. India has

probably recorded the biggest growth in ART centers and the number of ART cycles being

performed in our country has steadily risen over the last decade (Narendra Malhotra, 2013).

This shows how infertility rates are getting higher each day and moreover it can also mean

that Indian society is being more practical and is ready to deal such biological conditions

through medical aid.

Dr. Sonia Malik, emphasis the situation in India through her study. The total fertility rate for

India, measured as the number of children born to a woman, has fallen from 4.97 during

1975-80 to 2.3 for the current period of 2015-20. The NFHS4 (2015 -16) also indicates a

sharper fall in fertility amongst the urban population as compared to the rural This may be

welcome for the highly populated state of India that is burgeoning under its effect, but it also

points towards the trend of young couples unable to procreate. Interestingly, both male and

female partners are equally responsible for this decline. Though the proportion of women in

their reproductive age, that is, 20 to 44 years also increased in the last decade, it is majorly

the women over 30 who are under the burden of infertility in India.

Studies have indicated an overall pattern of decreasing fertility with increasing female

literacy rates. More educated women are more likely to postpone marriages and childbirth.

They also likely to opt for smaller family size and with the increase in per capita income,

there is a change in the lifestyle of both the urban and the rural populations. A study

comparing the Caucasians and Indian women found that Indians age five years ahead of their

European counterparts. The average age of menopause in India is 47 years as against 52 years

amongst the Western nations (Malik, 2020).

In India, religion plays a great role in one‟s life. Thus Anjana Chatterjee and Dr. Deepak

Kotecha say about how Hindu religion views the issue of infertility. Hinduism, being a

pluralistic belief system, allows for varied responses. However, sanctity of life is a key

principle in Hinduism along with karma. In traditional Hindu belief, having children is

viewed as one of the most important aspects of marriage. Conception is seen as a Divine act.

Infertility is sometimes seen as a result of karmic factor and women often go through social,

psychological and physical sufferings in varied degrees due to it. Infertility is understandably

very difficult to live within day-to-day life. In addition to pride, joy and self-esteem or self-

worth, there can be expectations and pressure from family or society, especially in Hinduism.

28

It is almost equally difficult to deal with emotionally by both parents, but the familial and

social stigmata in Hinduism are higher for the female, even in modern times (Kotecha, n.d).

2.3 History on treatment for infertility

Infertility has been a major medical and social preoccupation since the dawn of human

existence and women have always been the symbol of fertility. Since antiquity, couples have

been prolific and difficulty with conception was a real problem.

Indian Studies

Radhey Shyam Sharma et al., in the article explains that it was also evident from the Vedic

literature that the general population during that time was familiar with the idea of artificial

insemination (AI) which involved the manual injection of semen into the reproductive tract of

the women. Enchantment mixtures („Magic potions‟) created by the sages for the queen of

childless kings to make them pregnant was a typical practice during this era. Thus, the people

during that time were aware about the ideas of assisted conception and gamete manipulation.

The value of the women during Common Era was determined by her purity and after

marriage by her reproducibility.

Wide range of religious views on infertility existed from the late medieval period to the

middles ages where the concepts of gender equality came into existence; the necessity of

procreation was understood as important carrier of lineage ahead for the continuity and

extension of the family. Although religious discourse about infertility in those times focused

mainly on women, men also were considered as culprits for not producing the child. The

history of IVF in India for infertility treatments has come a long way. Just 69 days after the

birth of Louise Brown, Dr. Subhas Mukherjee - an Indian scientist from Kolkata announced

the birth of Kanupriya alias Durga following an IVF procedure using cryopreserved embryo

on October 3, 1978, world's second and India's first test tube baby. Dr Mukherjee developed

novel and relatively unknown techniques at that time such as use of gonadotropins for

ovarian stimulation, cryopreservation techniques, freezing, storing and thawing the embryos.

In 1982, the Indian Council of Medical Research (ICMR) a pioneering Indian organization in

the field of Biomedical Sciences took initiative realizing the importance of treatment of

infertility and initiated a project (led by T.C. Anand Kumar and Indira Hinduja) at its Institute

for Research in Reproduction (now ICMR-National Institute for Research in Reproductive

29

Health) at Mumbai. As a result, India's first fully scientifically documented test tube baby,

Harsha was born on August 6, 1986. Due to ever increasing demand for management of

infertility in country led to the mushrooming of the IVF clinics in the country. To regulate

these clinics the ICMR developed the National Guidelines for Accreditation, Supervision and

Regulation of ART Clinics in India in 2005 which were later translated into Assisted

Reproductive Technology (Regulation) Bill, 2017 and Surrogacy (Regulation) Bill, 2016

(Radhey Shyam Sharma, 2018).

Western Studies

In Egyptian society, women were equal to men, and difficulty with conception was not

considered divine punishment but an illness that had to be diagnosed and treated. As far back

as 1900 BC, there are recorded documents discussing the treatment of gynecologic disorders.

The gods played a fundamental role in treatment of childbirth. Infertility and its treatment

was to a great extend related to religion as Priests were the physicians and medicines were

permeated with magic. Examinations were based on the concept that the genital organs were

in continuity with the rest of the body and, in particular, with the digestive system. This way

of thinking remained in place for hundreds of years and was adopted by Hippocrates and

many medieval physicians. Knowledge about Jewish medicine on infertility could be

received through Bible. It shows that women were bound to be fruitful and replenish, giving

them no other rights and liberties. Pregnancy was considered a gift from God and children

conceived by the will of God were to be his servants.

Greece was the source of Western medicine. Hippocrates and his school developed a system

of medical reasoning based on rational thinking and avoided the element of magic in

medicine. The role of the Gods was just as important during the Roman era. During the feast

for Mars, the priests to this god would run through the city whipping the bellies of infertile

women with a goatskin whip. Many Roman physicians believed that conception took place

right after menstruation. The period prior to menstruation was infertile because the uterus was

overloaded. Galien (130-200 AD), believed that the phases of the moon had an effect on the

feminine cycle. There were little advancements in the treatment of infertility during Roman

times.

There were undeniable scientific progress and advancements in modern day thinking and

treatment of infertility during the Renaissance period. Da Vince and others made studies as

the mysteries of the female body were gradually resolved and scientific thinking and

30

reasoning replaced magic and the gods. In 1562, Bartolomeo recommended that husbands

should put their finger in the vagina after intercourse to encourage conception. This was the

ancestor of the idea of artificial insemination. The one to carry out experiments and describe

the fertilization process first was Smellie. Despite the progress that was made during these

times, infertility was almost synonymous with the female; and it was rare that the husband

was considered as a cause. Even during this age of enlightenment, a real ambiguity existed.

Women became the source of continual interest but were considered weak and sensitive

(Morice et al., 1995).

The nineteenth and twentieth centuries were marked by tremendous advances in the diagnosis

and treatment of infertility. In 1898, fertilization was described as the union of an egg and a

sperm. 80 years later, the first test-tube baby was born in England and in 1981, her in-vitro

sister was born. The first IVF baby born in the US was in 1981, pioneered by fertility

specialists at Eastern Virginia Medical School in Norfolk, Virginia. Since those early days, a

little more than 25 years ago, tremendous progress has been made in the understanding,

diagnosis and successful treatment of so many of the causes of infertility. And step by slow

step, infertile women have come to be considered patients in her own right, instead of a

curiosity and condemned member of the human society, living in silence and

misunderstanding no longer being considered witches and burned at the stake, but replaced as

the center of medical and scientific attention, and possibly lying at the very source of all

human survival (Arizona Center for Fertility Studies, 2015).

2.4 Reasons for Infertility

Indian Studies

In recent years, there have been advances in the understanding of management of infertility,

making it a speciality in its own. However, to manage appropriately, it is important to

identify the reason for the same. The causes of infertility are wide ranging such as ovulatory

disorders, tubal disease, endometriosis, chromosomal abnormalities, sperm factors, and

unexplained infertility. Among other factors thought to affect human fertility are the physical,

behavioural, genetic, socio-economic as well as environmental or occupational contaminants.

Lifestyle factors, such as psychological stress, advanced age to start a family, nutrition,

weight, physical exercise and occupational exposures, can also have substantial effects on

31

fertility and outcome. Further, other personal lifestyle factors, such as tobacco smoking and

chewing, illicit drug use, alcohol and excessive caffeine consumption, can also have negative

influence on fertility (Mittal, 2018).

Some other causes pointed out by Dr. Sonia Malik mentioned in her study titled, „Infertility‟

A Growing Concern for India. With lowering of social barriers coupled with an existing lack

of sexual health awareness, there is a rise in unprotected sex which leads to STDs and a

rampant use of the emergency contraception and surgical abortions. This also leads to serious

infections that may cause irreversible infertility. In the rural segment, the majority of women

are rendered infertile by genital infections like tuberculosis that leads to blockage of tubes.

Fertilizers and pesticides too are responsible for the declining fertility amongst the villagers.

This sharp decline in fertility is being attributed to environmental toxins, rampant use of

plastics, a change in diet that also contains chemicals and genetic mutations. The declining

sperm counts are also a cause for worry. While a small 4-5% may be due to treatable causes,

the majority of it is due to unknown causes. The exact cause is not known, but it is also being

attributed to similar causes as in women plus others including smoking, consumption of

alcohol and increased use of gadgets like mobile phones and laptops. But since the cause is

unknown, there seems no cure for it (Malik, 2020).

Western Studies

Infertility can be due to the woman, the man, both sexes, and unknown problems. Infertility

in men can be due to varicocele, trauma, and low or absent sperm count, sperm damage,

alcohol use, or certain disease like diabetes, cystic fibrosis, autoimmune diseases, infections,

hormonal disorders, and genetic disorders. Risk factors for men's infertility include alcohol

and drug use, toxins, smoking, age, health problems like obesity, medicines like testosterone,

radiation, excessive testicular heat, and chemotherapy. Risk factors for women's

infertility include ovulation problems like polycystic ovary syndrome, blocked fallopian

tubes, uterine problems, uterine fibroids, age, stress, poor diet, athletic training, and those risk

factors listed for men.

Aging is a major risk factor that decreases a woman's fertility. After age 35, about 33% of

couples have fertility problems. Older women's eggs are reduced in number, not as healthy,

and less likely to be released by the ovary. The woman is also more likely to have a

miscarriage and other health problems. Women under age 35 should try for a year and

women older than 35 should try for 6 months to become pregnant before contacting their

32

doctors if they have no health problems. Doctors use the histories of both partners and may

run tests such as sperm studies, ovulation tests, ultrasound, hysterosalpingography, or

laparoscopy. Infertility may be treated with medicine, surgery, artificial insemination, or

assisted reproductive technology, based on the couple‟s test results and other factors (Davis,

2016).

2.5 Impact of Infertility on Marital Relationship

Indian studies

Infertility is known to cause an impact on the mental health of the infertile couple, causing

anxiety, depression, social isolation and sexual dysfunction. The triad of the condition, its

investigation and treatment, the stigma associated with male and female infertility in

traditional societal interactions cause a high level of psychosocial distress with a direct

impact on the couple's marital and sexual relations. The pressure to conceive, programmed

approach to conception, loss of privacy to interventionists and the treatment itself negatively

impacts the marital adjustment and sexual functioning among infertile couples. In terms of

marital adjustment, the domains affected more severely were the cohesion between couples

and satisfaction with marital life, reflecting a strained relationship when compared to the

controls (Sameer Valsangkar, 2011).

The conflux of personal, interpersonal, social, and religious expectations may bring a sense of

failure, loss, and exclusion to those who are infertile. Relationships between couples can

become very strained when children are not forthcoming. One partner may seek to blame the

other as being defective or unwilling. Childless couples are sometimes excluded from taking

leading roles in important family functions and events such as birthdays, christenings,

confirmations, bar mitzvahs and weddings. Moreover, many religions assign important

ceremonial tasks to the couple„s children. Many societies are organized in such a way that

children are necessary for care and maintenance of older parents. Even in developed countries

with social support systems, children and family are expected to provide much of the care for

the elderly (Unisa, 2010).

The descriptive cross-sectional study conducted by Chhaya Kushwaha et al., in the year 2018

revealed that infertility affected the sexual life of participants as it was reported that even

though they still had regular sexual intercourse with their partners after realising they were

33

infertile (64.5%), sex was only for the purpose of reproduction and not for mutual sexual

satisfaction (13%). Sexual intercourse was reported to be unfulfilling as well as unenjoyable

(16.4%). The psychological well-being of participants (29.60%) and stability within marital

unions were also negatively affected by infertility, resulting in quarrels (13 %) (Chhaya

Kushwaha, 2018).

Western Studies

Peng Tao et al. conducted a review of several articles in the year 2012, to understand

behavior of marital relationship in infertility. The results indicated male factor infertility did

not have a negative marital impact. In addition, infertile male participants expressed higher

marital satisfaction than their wives. Infertile females had significantly less stable marital

relationship compared to fertile females, which was associated with their socio-demographics

and treatment experience. For infertile couples, the infertile subjects or their partners‟ marital

relationship was affected by either member's infertility, experience specifically coping

strategies. Moreover other factors such as sexual satisfaction, age of the infertile couples,

education level, and congruency of couples‟ perceptions of infertility were associated with

the quality of martial relationship (Peng Tao, 2012).

The study conducted by Dieime Elaine Pereira de Faria et al. in the year 2012, investigated

the effects of infertility on the spouses' relationship, with the objectives to describe the profile

of the studied population, and analyze the effects of infertility on their emotional, sexual and

marital life. To do this, a cross-sectional and prospective study was performed in a specialist

institution. The sample consisted of 50 infertile couples with a mean of six years of infertility.

The women manifested negative feelings in view of the infertility, while the men assumed an

attitude of support. The effects on the couples' sexual life were more pronounced in women,

and the infertility treatment resulted in positive changes for both spouses. No differences

were found regarding the effects of infertility between the women who had undergone more

than one treatment and those undergoing treatment for the first time between the men there

were differences in the emotional aspect (frustration and relief) and in the marital relationship

(strengthening and maturing). The socio-demographic variables of education, monthly

income, years of cohabitation, length of time of infertility, in vitro fertilization (IVF), and

intra cytoplasmic sperm injection (ICSI) were accountable for the negative changes in the

emotional aspects of the infertile couples (Dieime Elaine Pereira de Faria, 2012).

34

A qualitative research carried out by Nezihe Kizilkaya Beji in 2011, included 16 people who

received successful infertility treatment received in-depth interviews, and data collected

retrospectively. Infertility has negative effects on marital relationship and quality of life. It

was identified that infertility, regardless of which gender experiences it, brought along many

problems such as unhappiness, stress, sorrow, insomnia, increase/decrease in appetite,

increase in the smoking habit, social stigmatization, being exposed to curious questions about

having a child, avoiding being in places with children, losing privacy of sexual life, having

sexual intercourse in a planned way solely for the purpose of reproduction not of pleasure,

deterioration in family relations, interruption in work life, and high cost of treatment

expenses. Infertility and its treatment have effects on marital relationship and quality of life.

These effects varied depending on the stage of infertility process, gender, and the quality of

the relationship (Beji, 2011).

2.6 Consequences of Infertility

Indian Studies

Emotional distress in infertility is a broad expression that loosely denotes anxiety, depression,

grief, crisis, depleting psychological well-being, and all forms of affective and interpersonal

disturbances faced by individuals with infertility. The distress is usually associated with

involuntary childlessness as it is an unwelcoming event. The developmental crisis associated

with childlessness poses a threat to one's sense of self at all levels (individual, family and

social). Distress may begin before or during treatments as a person experiences the loss of

control over attaining parenthood, anxiety or dejection after the diagnosis, treatments, its

complications particularly its limited success rates.

The self-regulatory perspective integrates the roles of cognitive representations, health

beliefs, and emotional representations in infertility. The uncontrollability, ambiguity, and

uncertainty associated with this medical condition are significant which explains why for a

majority of patients, infertility turns into an unbearable stressor. Infertility may also be a

stigmatizing and shame-laden experience. Infertile men and women are perceived by others

to be 'defective and socially deviant', adding to their feelings of guilt and inferiority. Children

are viewed as an extension of oneself and one's family lineage. From these perspectives,

35

infertility causes a blow to one's self-concept, self-image leading to narcissistic self-injury

(Ansha Patel, 2018).

Infertility affects the couple, not the individual hence the burden is on the family. The

findings of the present study revealed that infertile couples have poor well- being on all the

dimensions. They have negative feelings, low self-esteem, and low social support. Infertility

is not mere medical problem of the affected couples alone but is highly influenced by the

social and psychological conditions. It has profound effect on people's lives and psyche.

Female literacy and counselling helps them to overcome the psychological negative feeling

towards infertility and brings confidence and it may help them to overcome the stigma (Vidya

V. Patil, 2017).

Western Studies

Infertility is best understood as a socially constructed process whereby individuals come to

define their ability to have children as a problem, to define the nature of that problem and to

construct an appropriate course of action. Because it involves an inability to achieve a desired

social role, infertility is often associated with psychological distress. He made the conclusion

that infertility is a fundamentally different experience for women than for men (Arthur L.

Greil, 2010).

Infertility, besides being a medical condition, is a social situation. Infertility is a low-control,

chronic stressor with severe long-lasting negative social and psychological consequences.

Achieving a pregnancy/delivery after assisted reproduction technology treatment is

associated with increased mental well-being. Treatment failure is associated with increased

levels of anxiety and depression during the treatment period and after end of treatment. It is

still unclear whether depression and/or fertility problem stress is related to treatment

outcome. Some infertile couples experience marital benefit, i.e., that the infertility brings the

partner closer together and strengthens their marriage. Long-term studies among involuntary

childless women in previous unsuccessful treatment show that although most adjusted well

psychologically the childlessness was a major life theme. Drop-out rates of treatment are high

and are mostly related to the psychological burden (Schmidt, 2010).

Family plays an important role in the experiences of the infertile couple. Economic

consequences are a particular distressing factor. There is a need for psychological counselling

in the treatment of infertile couples. It should be realised that in developing countries, despite

36

overpopulation, unwanted childlessness is an important social and financial burden that needs

attention (Wiersema, 2006).

A document published by Harward Medical School gave the summary of several studies

concluded that, while the causes of infertility are overwhelmingly physiological, the resulting

heartache often exacerbated by the physical and emotional rigors of infertility treatment may

exact a huge psychological toll. One study of 200 couples seen consecutively at a fertility

clinic, for example, found that half of the women and 15% of the men said that infertility was

the most upsetting experience of their lives. Another study of 488 American women who

filled out a standard psychological questionnaire before undergoing a stress reduction

program concluded that women with infertility felt as anxious or depressed as those

diagnosed with cancer, hypertension, or recovering from a heart attack.

Less research has been done on men's reactions to infertility, but they tend to report

experiencing less distress than women. However, one study found that men's reactions may

depend on whether they or their partners are diagnosed with infertility. When the problem is

diagnosed in their wives or partners, men does not report being as distressed as the women

do. But when men learn that they are the ones who are infertile, they experience the same

levels of low self- esteem, stigma, and depression as infertile women do.

Drugs and hormones used to treat infertility may cause a variety of psychological side effects.

For example, the synthetic estrogen clomiphene citrate (Clomid, Serophene), frequently

prescribed because it improves ovulation and increases sperm production, may cause anxiety,

sleep interruptions, mood swings, and irritability in women. (These side effects have not been

documented in men.) Other infertility medications may cause depression, mania, irritability,

and thinking problems. Patients and clinicians may find it hard to figure out which reactions

are psychological and which are caused by medications yet identifying causes is essential for

determining next steps (Harward Health Publishing, 2009).

2.7 Coping Strategies adopted by Couples with Infertility

Indian Studies

37

Coping strategies refer to the individual„s cognitive ability to control and manage a stressful

life event. The goal of coping can be altering the problem (problem-focused coping) or

reducing the emotional disturbance (emotion-focused coping).

Selection of a coping strategy depends on the type of crisis and individual„s interactions with

the dominant factors within the family and society. The results from the study showed that

females scored higher seeking social support and escape avoidance than males. Infertility is a

painful problem for couples who are interested in having a child. Several factors can affect

the similar emotion and problem-focused coping of a couple against stressful circumstances

such as similar emotional and psychological factors, same living state, same social

characteristics, same relatives and etc. However, no significant difference was found between

couples according to problem- focused coping and emotion-focused coping scores. In

contrast, males had more self-control. Infertile women are more prone to experience grief and

depression and hence coping strategy skills can lead to less considerable distress comparing

to men. The finding of the study showed that, husbands have more Problem focused coping

style and wives have more Emotion focused coping style (Maryam Mohammadi, 2018).

Within Indian contexts, limited studies are available on the coping patterns in infertility.

Evidences from cross-sectional studies suggest that coping difficulties are reported by nearly

57% of men (172 out of 300) and 72% of women (215 out of 300 women) seeking fertility

treatments such as ovulation induction and assisted conception. Studies report that both sub-

fertile men and women mostly cope on their own or by seeking consolation, information, and

advice from family and friends. However, they express lack of confidence in their coping

capacities. Women primarily adopt strategies such as use of self-controlling, seeking social

support, venting, behavioural disengagement, and ruminative thinking. In addition, most of

them report that they are unable to effectively employ the use of strategies such as problem-

solving, mental mastery, positive appraisal, recreation of life around other goals, and seeking

alternative rewards to resolve infertility distress. Men report of employing the avoidance and

escapist coping approach to deal with fertility-related stress (Ansha Patel, 2018).

Western Studies

Infertility can lead to major bio-psychological disorders. Coping strategies help individuals

adapt to unpredictable conditions in a systematic way. The present study aimed to determine

the perceived stress of couples undergoing treatment for infertility, as well as their coping

strategies. The obtained results suggest that the mean score of perceived stress is higher in

38

women. Moreover, women more frequently use problem-focused mechanisms, while men

more frequently use emotion-focused mechanisms (Leili Mosalanejad, 2018).

Although understudied, partner coping patterns play a key role in a partner‟s ability to cope

with the infertility experience. A partner‟s use of active-avoidance coping was related to the

increased personal, marital and social distress for men and women. A woman‟s use of active-

confronting coping was related to increased male marital distress. And a partner‟s use of

meaning-based coping was associated with decreased marital distress in men and increased

social distress in women (B.D. Peterson, 2008).

CONCLUSION

Even though there has been innumerable studies related to infertility and its consequences,

covering several aspects of the same, most of the studies focused on how people individually

dealt with the situation. Women are labelled responsible to carry the burden of infertility just

because, they conceive and give birth to the baby. Since men and women are equally

responsible for fertility issues, there must be more studies that focus on both of them with

equal importance. Couples must be considered as an inseparable factor when it comes to

infertility that affects both, be it physically, emotionally, socially or financially. Such studies

are lesser in number, especially in Kerala context.

39

CHAPTER 3

METHODOLOGY

40

RESEARCH METHODOLOGY

3.1 INTRODUCTION

The present chapter deals with the methodology adopted for the purpose of this study. This

chapter includes the research design, the setting of the study, population, sampling, tools, and

method of data collection and how the data will be analyzed appropriately and interpreted in

order to arrive at the findings and conclusion.

3.2 TITLE OF THE STUDY

Lived Experience of Couples undergoing Infertility Treatment at N Superspeciality

Hospital, Adoor.

3.3 RESEARCH QUESTIONS

1. How do the couples experience infertility as a life event?

2. What were the challenges faced by them before starting treatment for infertility?

3. What were the factors influencing decision making and choice of the treatment?

4. What are the challenges faced by the couple while undergoing the treatment for

infertility?

5. How do the couples, individually and together cope up with the problems related to

infertility?

3.4 DEFINITION OF CONCEPTS

Conceptual definition:

• Couples with infertility- couples who could not conceive naturally after one year of

regular unprotected sexual intercourse.

• Challenges- something new and difficult which requires great effort and determination.

• Experience- an event or occurrence which leaves an impression on someone

41

• Decision making- the process of making choices by gathering information, and assessing

alternative resolutions.

• Coping strategy - an action, a series of actions, or a thought process used in meeting a

stressful or unpleasant situation or in modifying one's reaction to such a situation.

• Lived Experience- a representation and understanding of a researcher or research

subject's human experiences, choices, and options

Operational definition:

• Couples with infertility – couples with primary infertility- couples who could not

conceive naturally after one year of regular unprotected sexual intercourse and also took

minimum 2 years of treatments for infertility at N Superspeciality Hospital, Adoor.

• Challenges- difficulties - psycho-social and economic - that the couple have to face due

to infertility and as part of undergoing the treatment for infertility.

• Experience- life events - positive or negative - in a couple„s life arising out of an

experience of being detected infertile and as part of undergoing the treatment for

infertility.

• Decision making- considerations on arriving at a choice regarding the need for treatment

for infertility, the place and treatment method.

• Coping strategy- The specific efforts or actions, taken by the couple, individually and

together to handle the challenges arising due to infertility and as part of undergoing the

treatment for infertility.

• Lived Experience- phenomenological representations and understanding of the

experiences, choices, and options in the lives of couples with infertility and as part of

them undergoing treatments for infertility.

3.5 RESEARCH APRROACH

As the theme was very inextricably linked to the lives of couples, the study demanded in-

depth understanding of the couple„s experience with infertility and treatment for infertility.

Hence the study adopted a qualitative approach.

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3.6 PILOT STUDY

The researcher assessed the feasibility of the study and the availability of the respondents

through the pilot study. Researcher interacted with one couple at N Superspecialty Hospital,

Adoor, to assess the feasibility of the present study. Based on the pilot study appropriate

modifications were made to the data collection tools to serve the purpose.

3.7 RESEARCH DESIGN

The researcher adopted multiple case study design for detailed and intensive analysis of each

cases. The study is descriptive in nature. The basic case study entails the experience on

various dimensions, of couples undergoing treatments for infertility.

3.8 UNIVERSE AND UNIT

The universe of the study includes all Couples undergoing treatments at N

Superspeciality Hospital, Adoor.

The unit of the study is a single couple undergoing fertility treatment at N

Superspeciality Hospital, Adoor, for more than two years.

3.9 SAMPLING STRATEGY

Purposive sampling method was used to select the samples for this study. The samples were

selected based on the criteria„s given below:

Inclusion criteria

• Couples undergoing treatments for infertility for more than 2 years were selected as

samples for the study.

• Couples belonging to middle class family

• Couples with primary infertility

Exclusion criteria

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• Couples undergoing treatments for infertility for less than 2 years are not considered

while selecting samples.

• Couples belonging to lower class and upper class family background are not considered.

• Couples with secondary infertility

3.10 SAMPLE SIZE

Three samples were selected for the purpose of the study. Each sample constitute two case

studies. The samples were selected based on the inclusion criteria mentioned above.

3.11 TOOLS FOR DATA COLLECTION

Interview schedule was prepared to collect demographic details of the couples. A semi

structured interview guide with 16 questions was prepared based on the research questions set

by the researcher. The data was collected through face to face interviews.

3.12 DATA COLLECTION

Primary data was collected by visiting the hospital on a working day when couples visited the

doctor. Time was allocated for the researcher, by the hospital authorities, to interview the

couples for data collection. The couples were personally interviewed. Data collection was

done in Malayalam, using semi-structured interview guide and it was later translated into

English. The secondary data was collected from interviews, documents, books, reports of

surveys and studies, literature dealing with infertility, treatments and its impacts.

3.13 DATA ANALYSIS

The data collected through in-depth interviews were subjected to the process of analysis to

glean new understanding. The analysis of the qualitative cases studies was done through

thematic analysis.

3.14 CHAPTERIZATION

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Chapter 1 – Introduction

Chapter 2 – Literature Review

Chapter 3 – Methodology

Chapter 4 – Case Description / Narratives

Chapter 5– Thematic Analysis and Discussion

Chapter 6 – Findings, Suggestions and Conclusions Chapter 7 –Reference and Appendixes

3.15 ETHICAL CONSIDERATION

Permission was taken from the Head of the Department of Social Work and the ethical

committee of the hospital management before approaching the couples. As instructed by the

HR Department of the hospital, the questions to be asked where put before the department

counsellor for approval prior to the data collection. Verbal consent was taken from all the

respondents before conducting the interview after communicating with them the purpose of

the study and affirming that full confidentiality would be maintained and the data collected

would be used solely for the purpose of this study.

3.16 LIMITATIONS OF THE STUDY

• It was difficult to find clinics that would permit the researcher to conduct the study in this

particular area.

• It was very difficult to get samples who were willing to provide information for the study.

• As per the hospital instructions time limit was set for data collection, which was constrain

for the researcher.

• The findings cannot be generalized as the samples were taken only from one clinic.

3.17 CONCLUSION

This chapter describes the methodology used for conducting this research. It gives an over

view of how the study was planned and executed.

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CHAPTER 4

CASE DESCRIPTION

46

CASE DESCRIPTION

4.1 Sample 1

4.1.1 Case study 1(A)

A is a 30 year old female who worked as a nurse for a few years. She lives in Kundara, a

place in Kollam district. She lived with her parents and her only sibling before marriage. It„s

been 7 years since A got married to a person who is 8 years elder to her. Even though her

husband worked in Abu Dhabi, A spent almost the whole of 7 years with him as she went

along with her husband for being together and also for the purpose of conceiving a child.

A looked lean, under nourished and also her pale face reflected the weight of her heart while

being in conversation with the researcher. 5 years of treatments for infertility from various

hospitals and failure that resulted in major breakdowns has brought her to a place where she

believes would be the last ray of hope. A started taking treatment from the 2nd year of

marriage. The first treatment was taken from Kottiyam General Hospital. A was diagnosed

with Endometriosis and was asked to do Laparoscopy. Soon after doing that, her husband was

tested with low sperm count and low sperm motility. The treatment was done as the couples

came for leave from Abudabi. Since the hospital was found to be not the best place for

treatments for infertility, A was suggested to shift to another hospital in Muvattupuzha.

It was during that time, A was subjected to In Vitro Fertilisation (IVF). Everything was done

carefully and the surgery was considered a success until it was found that the implantation

happened inside the fallopian tube. Since the situation, the doctor suggested the removal of

that particular tube to avoid medical emergency. And finally one of the fallopian tubes was

surgically removed and laparoscopy was once again conducted. This decreased the number of

eggs produced each month. When asked about this incident, A shared:

“I went with the dream of conceiving a baby and came back losing one of my tubes that

produced eggs. This naturally decreased the probability of me getting a baby in future. I was

devastated and even thought of never trying for this again. I wished for something every wed

woman would wish for. God not only did not answer my prayers, but also lowered the chance

of fulfilling my dream anytime in future. I was exhausted think about the mental and financial

burden that my family was having because of this”

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For a while they paused all treatments for a while. It was then her husband„s friend suggested

them this hospital where even his friend along with his wife took treatment for the same

issue. They have been in treatment at the hospital for about 4 months and were planning for

their next IVF. Since A had only one fallopian tube, egg production reduced to half and thus

she had to take medication to increase the production of ovum. Both A and her husband had

to take injections and medicines for different reasons but for the same purpose. “I still

remember the day doctor told us we both had problems conceiving a child, and that, it might

take some time for us to get what we wished for. We were ready to wait and were so

optimistic until what happened at Muvattupuzha Hospital”

A had a god-fearing family. They were really close to God and never missed a day at church.

All the problems that she faced in life made her get even closer to God. Spirituality helped

her to get peace of mind. She used to visit many churches to pray for a child. Prayer was a

healthy strategy for her to console herself and her husband. As “A” mentioned, they accepted

their issue without any difficulty and decided to start the treatment as early as possible. At

first the decision was to try only by taking medicines. They tried that way for a year but did

not find any result.

Hormone injections and medications disturbed her hormonal balance and cause

hypothyroidism. She then had to make changes in her medications as it started affecting her

health and physique. “One day I started noticing that I was gaining weight. This unexplained

weight gain made my doctor suggest me to do test to check thyroid level. I did other tests for

PCOS too. That was normal in my case. Most people have PCOS that leads to infertility. That

was not the situation in my case”.

A had a strong support system. Both her parents and in-laws were very supportive. No one

blamed her for anything. Her dad died in 2018. “He wanted me to have a child more than

anyone else. His death made me go helpless. He was my strength and support. My mother

became stronger after his death and now consoles me more than anyone. She never let me

know the gap that my father‟s death caused” Other than the family members, A had a friend

to whom she shared everything about her life. She could shed off her pain to that person other

than her husband. Thus she relayed upon a few people in life for this matter.

A has lost interest in socializing since a few years. She avoided attending social functions to

get rid of people enquiring about having a child. Even if she attended function, she would

make sure that she leaves the place before people came to talked to her. “There were people

48

who suggested several hospitals for treatment. Most of them understood that infertility is very

common and there are treatments for that. But the thing is that they never came to me but

talked to my parents to inform me. Some of them intentionally waited for me to leave church

on Sundays to ask me about this every week. Sometimes it became intolerable” As her

husband took leave for 2 years and stayed with her for the purpose of the treatment, she

became stronger. She started facing people and answering questions. She never gave anyone

the details of the treatment but made sure to tell them that they have some issues and is taking

treatment from a good hospital.

Financial burden related to treatments for infertility has affected them mildly. Since a few

years, her husband kept aside money for the treatments alone. They spent almost 1.25 lakh

money for doing one IVF which resulted in vain. They had housing loans too as liabilities.

But still they could manage the situation as “getting a child was more important than any

amount of money” A no longer went for work as she wanted her full attention to be given to

the treatment. It was only with what her husband earned that they led their life.

A was once suggested to attend a counselling session by a doctor but she never took initiative

for that. Even when she could not hold things together, she never thought of seeking help

from someone like a counsellor to help her as she was never aware of what she would get

from such a person. There were situations like her father„s death that disturbed her so much

along with infertility issue. But she never ever thought to reach out to someone for help as

she was ignorant about something like that even after working in a medical field for some

years. Faith in God was her only way of getting over the stress. She indulged herself in prayer

and became more spiritual. “I believe in god, so does my husband. He was never an ardent

believer, but became one for me. He was always there with me throughout this. I can never

thank him enough. We wished for a baby together and God will fulfil our dream”, said A

with teary eyes.

4.1.2 Case study 1(B)

B is a 38 year old who worked at Abudabi for the past 14 years. Kundara was his native place

in Kerala. He worked as an Engineer at a construction company. Within one year after B got

married to a person who was a nurse, he took her along with him to Abudabi. Their life was

smoothly sliding through until they started trying to conceive a child. Just like any person, he

49

wished to have a child and live a happy life. He had his new house being constructed in

Kerala and according to his calculation it might take almost 2 years for the completion of the

construction depending on the money flow. “I wanted to do the house warming along my

family and that included my child too. We all wished for that. During those days we were

confident about that too.

They tried one year to conceive a child and failed to do that. It was then they felt the need to

consult a doctor. First consultation was done at Kottiyam where he came to know about that

he had low sperm count and sperm motility issues. He decided to reach to a better hospital for

starting treatment. He chose a hospital in Muvattupuzha for this purpose. He along with his

wife had to travel very long distance and even wait for 2 days to meet the doctor. He felt

weak and exhausted after this for several times. It was at that hospital that his wife underwent

IVF. That resulted in an unsuccessful outcome and made the situation even worse. As he

shared about the incident:

“I didn‟t know how to console my wife. She was the one who was very much interested in the

treatment as she had great hope. The outcome was not what we all expected and that made

the health condition even worse. We left the hospital with teary eyes. That incident made me

realize that I must be more supportive for my wife and also my family”

Soon after that incident, the couples decided to give a break to the treatment and look up for a

better place to seek treatment form. As suggested by one of B„s friend they approached

another hospital where they started to prepare for the next IVF. B has been taking medication

for sperm count and motility problem. They have been under treatment for almost 5 years of

married life. It was during their 2nd year that they started with the treatment. Even though it

was difficult to make everything clear to the family about the issue, B found it relieving to get

support from both the families. He had friends who supported him throughout the journey.

His friend and wife who underwent treatment for infertility supported him mentally to get

through all the anxiety related to it. They also helped B‟s wife to bring faith in whatever

treatment they were undergoing.

B was not a strong believer of God. He visited churches along with his wife to satisfy her

wish. He made changes in his life to support her. He never showed disrespect to whatever his

wife was up to as he understood the difficulty of a woman who had to face a problem of not

being able to conceive a child. She was the one being blamed for their infertility by many

people among their relatives and neighbours. “Nobody came to us asking about the problem.

50

Some straight away suggested hospitals for treatment, some blamed my wife for not being

able to be a mother and some others thought it was because we planned not to have children

for at least 2 years after marriage and now we cannot conceive. People make up stories but

that has never affected me. But unknowingly I started avoiding being in a group”

Without his own knowledge, B showed social withdrawal. Even though he used to attend

social functions, he never used to be in groups so as to avoid people coming up with

questions about treatment. This happened to him only while being in Kerala. As he said: “It

was a very common issue in Gulf. I have never felt any difficulty in discussing about this to

anyone there in my workplace. People were more accepting because majority of the people

there had some issue or the other related to sexual life”.

Since B had to stay at Kerala for 2 years continuously for the treatment, he had to adjust with

the situation and act according to it. Taking leave for 2 years left him with financial burden.

Since the previous IVF cause more than a lakh and other treatments were expensive too he

had to manage money carefully. As he was in need of a house on his own, he had to look

after his house construction in parallel. He used to make a saving for the treatment itself from

the day he came to know about the issue. “We would sell anything so that we could to do the

right treatment to have a baby. We both love babies so much. Seeing new born babies with

their parents while we wait outside doctor‟s room always gives us a ray of hope” He had no

one else to support him financially and because his wife resigned from her job for the matter

of getting treatment, all the expenditure had to be managed from whatever he had earned

before. Since he did not have any other liabilities other than housing loan, he was able to

manage the expenses of the treatment.

Weight gain was one issue he faced while taking medicines to increase sperm count. He

confused that with food habits he followed while being abroad. This was rectified consulting

the doctor. The hospital provided him with services from a dietician which helped him to

manage his weight gain. Several check-ups were done timely to achieve the best out of the

treatments being conducted. B was more careful about everything this time as one more

failure might affect him and his wife in many ways.

There was always a way to find solution for his physical need. Even though counselling was

suggested by doctors, he has never attended anything other than pre-marital counselling. He

consoled himself when he felt low. Being with his wife for the past two years at home made

him understand the intensity of what she was going through in a society that never tried to

51

understand what the actual situation was. As he noticed changes in her regarding how much

insecure she felt, he tried to talk to her more and tried to make her stronger. He made her

capable of telling people that there was a solution for the issue which they were facing

currently. “Nobody could blame her alone. I am equally responsible for our issue. She might

not stress my issue to anyone. She was brought up in such a family where men were given

more importance over women. But I supported her more in front of others for being so brave

throughout the treatment. She needs to be encouraged in front of people, only then she would

feel confident”.

Recounting the entire painful situation he was going through, B looked more focused than he

was at the beginning of the conversation with the researcher. B had a dream and he was at the

hospital to fulfil that. Researcher had one last question to him: ―What do you think

your life would be in the next 10 years?” for which he answered:

“Insha Allah! I will have a child in my life. I might leave my job in Abudabi and start

working here. I would not be able to leave my wife and child here anymore. It is a life I

wished for and prayed for. And also, we will do the house warming of our new house and live

there”.

4.2 Sample 2

4.2.1 Case study 2(C)

C is of the age of 28 and she has been married for 5 years. C lives with her husband and in-

laws in Mallappally, a place in Kottayam district, Kerala. C was a post graduate in

Commerce. Soon after completing her studies, she got married to a person whom she loved.

He worked as a driver in Dubai. One after the marriage, her husband had to leave to Dubai so

as to maintain his job. C was engaged in PSC coaching classes during that time. It took next

one and half years for her husband to come back to his native place again.

C had an inconsistent sexual life with her husband as he was abroad for most the times. From

the second year of their marriage onwards, her husband used to visit her often. This did not

help them both to conceive a child. Thus, now, C and her husband live together since past 1

year as part of taking the treatment. C shared:

52

“He is in the verge of losing the job. He wasn‟t supposed to take leave for so long. But that‟s

okay. Let us make a stand on this. Job is not the priority, our life is”.

C and her husband have started taking the treatment from 2017. They have never undergone

any IVF treatments even if that was recommended by the doctor. She chose to try for a

normal pregnancy with the help of medications. Her first treatment was done in a hospital in

Mallapally. The doctor there prescribed IVF as soon as the consultation started. This made

them lose hope in that doctor as they think it was a part of their business. She believes she

can conceive without IVF but with the help of some medicines. “As he was abroad for so

long after marriage, we didn‟t feel the need to do a treatment. But once he came for a

vacation for almost 4 months, we tried our best to conceive but failed to. Then we sensed

something wrong. My grandmother was falling sick gradually and she wanted to see my child

before dying. We did not have an answer for their questions. It was then that we decided to

consult a doctor”.

During C„s first consultation with a doctor from a hospital in Kottayam district, he straight

away mentioned about the positives of doing IVF. They were asked to do basic testes which

they failed to. Later they approached the hospital they are currently taking treatments from.

After doing the testes they came to know that, C had cysts inside the uterus and egg

maturation was insufficient. Ovulation was properly taking place but its maturation was very

slow. This caused inability to conceive. Adding on to this problem was husband„s low sperm

count. It was able to bring the problem under control with the help of medications but

conceiving a child with immature ovum and low sperm count was of very low chances. Even

though IVF was the best possible way to make a better result, making a decision on this was

something C could not do till now.

Weight gain was the only outward physical issue that she suffered from taking medicines.

She was afraid of forming cysts again in the uterus. And thus was obsessed with doing

scanning to reassure that cysts were not growing inside her anymore. This made her more

anxious.

Family was her support system. She had her parents, one elder and one younger sister as

family. Her elder sister who worked abroad as a nurse was her guide for everything. C

cleared her doubts and shared her fears with sister. She was close with her mother too. C

could talk anything with her husband but he was engaged in his own matter all the time. C

shared:

53

“My sister became more close to me when after I was diagnosed with such difficulties in

having a child. Now, she calls me every day and consoles me when I breakdown. She too had

a similar issue in conceiving a child. But it took her only a year‟s treatment to become

alright. Right now I am worried about my younger sister. She is not yet married and if

someone comes to know that we both had such issues, sometimes it can affect her life too”.

C recounts how people suggested her to take Ayurvedic medicine and how some blamed of

her poor health as she was very lean. C avoided all possible family functions and social

gathering to avoid questions. She described how people reacted to her usually, “they might

ask me how long my husband has been here in Kerala and then make faces. Old people would

start advising me saying that I must not wait for so long to get a job and then have a child.

People my age usually understood the situation. I usually do not spend time to make people

convinced but rather run away from places where I might have to talk to my relatives and

other people”.

C found her husband not very much concerned about the issue. Even though he does not have

a proper job in Kerala but works as a driver occasionally, he had friends to hang out with.

“I am the one who had to sit at home and overthink about all that might happen to us in

future. He has friends and some thing or the other to get engaged with. I have already

stopped preparing for PSC exams. I cannot concentrate anymore”.

One thing that C could not do was to make a decision on what kind of treatment was to be

taken. The fact that infertility existed was for her something unacceptable. Getting married to

someone she loved for many years before marriage made her unable to think of a situation

like this to happen in life. All that she did was to clear doubts about infertility but did not

accept she has some kind of infertility issues and will have to face the consequences of it. C

has never attended any counselling sessions even though she was suggested to. This was to

make her capable of taking a decision and believe in it.

C had several financial liabilities. Since her husband was out of a job and had immense

expenses due to the treatment, financial burden was an issue. She was not much aware about

the savings or how money flow would be resumed. “My husband would take care of all

those. I do not have the capacity to think of that part too. I am already suffering a lot”.

C has not developed any coping strategies other than talking to her sister. She has nothing

else to do at home other than overthinking and worrying about having a child before the age

54

of 30. She never talks to her friends as everyone had a child or two. She avoided calls and

meetings with them. Thus there is none for her to reach out other than the family members.

The thought about her younger sister worsened the situation even more. “I am afraid my

younger sister would start hating me if she does not get any good alliance. I pray to God for

her”.

Her life revolved around whatever was good for her husband, he loved to spend more time

with him and visit places with him. After knowing about the issues and treatments were

started she travelled only with her husband to avoid facing others„questions and opinions. C

was not able to face a problem on her own but rather found ways to run away from it. She

was ready to suffer anything for her husband or for a child but was never ready to find a

better way out of it. C was in need of a person to make her strong enough to face life and the

atrocities that comes along with it. “Sometimes I worry too much that I forget to take

medicines. I need to, at the very least, conceive a baby. Carrying a baby throughout the

pregnancy period and giving birth to the baby is another thing. At least then I could say

people that I wasn‟t that much incapable”.

4.2.2 Case study 2(D)

D is a 28 year old who worked as a driver in Dubai. His native place is Mallapally. He lived

with his parents and sister, who got married recently. D has been working as a driver from his

17th year onwards. By the age of 24, he got married to a girl whom he loved for several

years. She was post graduate in Commerce. D led a peaceful life and migrated abroad in

search for a better job in order to earn more money to pay back loans that he took for several

purposes.

D had been under treatment for infertility from the past 2 years along with his wife. Even

though IVF was suggested by a doctor from another hospital, he was not convinced by the

diagnosis and went for second opinion. He approached the hospital from where he is

currently taking treatment because of that reason. D had low sperm count issues. Several tests

were done to get a holistic view of the problem. “The attitude of the doctor was much

pleasing than the one to whom we made consultation before. Here we feel more secure and

there is a hope of getting a baby”.

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“I had to leave my wife a year after the marriage. It was painful and I could not take her

along with me because I did not have any proper living space there. I lived in a place where

more than 10 people stayed in a big bedroom. At that time we thought we had enough time to

think of a child” Even though it was painful, D had to leave her wife to go back to job as he

was the only earning member of the house. He had other responsibilities other than being a

husband. He had to take care of his parents and marry off a sister too. “She knew my

situation even before marriage. That was a relief for me. Her parents were not very happy to

marry off their daughter to a driver like me. That was why I wanted to earn more money and

look after her to convince them too”.

D had a very supportive family. They never blamed his wife not getting a job or not being

able to conceive. D used to visit the family almost every year. It was then his wife„s

grandmother fell sick. He wanted to see them have a child. People forced him to take a leave

for atleast more than 4 months to stay with his wife as it was “high time they had a child”.

Even though the demand gave him a good amount of stress, it was then he himself along with

his wife felt the need to seriously think about a child. Even though he had been on vacation to

Kerala several times before, not being able to conceive was not an issue because they never

thought about the reason behind it. D believed everything was normal until then. Her sister-

in-law who was a nurse in Gulf helped them with providing necessary guidance at the time of

treatment. Even after 2 years of undergoing treatment, D seemed to be confused regarding the

situation, progress and further procedures in the treatment.

D had several friends as he was a driver since his teenage. But he refused to discuss any of

his problems with anyone. He used to be in groups for very long time. He left home each day

even if he had work or not. He avoided staying inside the house to avoid being sad thinking

about how everyone wanted them to have a child but they are not able to do it.

“My wife complains that I do not stay with her at home when there is no work. That is true.

But that is not because I do not love her. I want my self to be engaged in something or the

other. It helps me forget the pain. In the other way, when I am outside sometimes people

would call for work and I could earn some money too” D avoided visiting his wife house

intentionally as he always felt guilty of ruining his wife„s life.

D had to follow instructions given by the Dietician. He was over-weight for the treatment and

also had drinking habit. Drinking was always an issue in his life. He never had to answer

everyone„s questions before as he was abroad and everyone living with him used alcohol. But

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once he started living with the family, he could not stop using drinks but also had to deal with

how people reacted to this habit of his. He was asked not to drink anymore, but could not stop

it as that was the only thing that gave him a relief. He has already tried to stop the habit more

than once, but could not sustain that for a week or two.

Financial issue was the one that disturbed D so much. He was the only earning member of the

house and thus had to look for an alternative when it came to making money even when he

had to take leave from the one he was doing. D went for work occasionally when got a

chance to. The medicines for the treatment were also very expensive. He had his old parents

who needed medical care. D also had loans to repay. Another thing that gave him pressure

was his job in Dubai. He had to leave soon or he loses his job. D could not do that because he

was undergoing treatment. “What would I do? I am in the verge of a financial breakdown. I

would not let my parents or wife know that. She already has several things to worry about.

My parents are old and cannot help me earn money. I wish my wife had a job to support me

financial. I will somehow manage”.

D was found to be confused while talking about several things to the researcher. He was not

clear about the treatment or the consequences of doing it. He merely followed what the doctor

said to do and took medicines according to his prescription. D was not confident to talk to the

doctor anyone else regarding the issue as he felt he did not have enough education to talk

about these. He avoided situation were his doubts were to be cleared. He was afraid whether

his drinking habit would worsen the situation. He wished to clear that doubt to someone but

never could as he thought he did not have the education to understand why. D looked like a

person who wanted someone to clear his doubts and help him with dealing with his stress. He

had no one to share his problems with, nor friends or relatives. A space for ventilation was

absent in his case. As D shared:

“I felt like it was better not to share my problems with anyone. No one could help me with

this, then why bother others? I had a few friends who helped me get chances to go as driver

when in Kerala. They were always with me since my childhood days. I cannot let them show

sympathy to me. Let this be like this for now. My sister-in-law helps us with matters

regarding the treatment. That would be enough”.

D behaved restless as he was talking about his financial issue. He could not but show his

helplessness that he was going through. He shared to the researcher his problem regarding,

money, more than his infertility. He had a hope that soon he would be able to have a child. “I

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do not think that we will have to wait for so long to have a child. I believe that the treatment

here is good but just like any other places, expenses are not manageable for someone like

us”.

4.3 Sample 3

4.3.1 Case study 3(G)

G is a 43 year old working as a Jail Superintendent in Kannur. G lives with her husband away

from her parents and in-laws. G got married when she 30 years of age. G waited to get a

government job during her twenties and thus according to her, ended up in a “late marriage”.

G was a less talkative person and her closed nature acted negatively for the Researcher in the

purpose of collecting data.

G was born and brought up in a family where her father was a farmer, mother a homemaker

and two siblings who all got married off eventually. G was a person who had clear aims and

goals in life and thus worked towards its achievement with full heart. It took G some time to

settle in life and during that time having a child was not a priority. Once everything like a job,

a house of her own, a permanent job for husband and so on was settled, “it was high time”

that they had a child.

It was during the 5th year of marriage that G felt the need to meet a doctor to seek help for

why she was not able to conceive. G took treatment from Kannur itself where nothing

abnormal was diagnosed. Medications were given to consume and wait for normal

pregnancy. Treatment was taken for almost 2 years which did not show any promised results.

Later G and her husband took treatments from hospitals in Kozhikode and Payyanur. IVF

was done for the first time in Payyannur hospital. The attempt of IVF failed and that

devastated G. G could not stay away from her job for so long and decided not to do IVF for

the second time any time closer. There was a gap taken after the treatment from Kannur. It

was during their 13th year of marriage that G approached the hospital where she was taking

the treatment from currently.

As G saw an advertisement in newspaper about the ―Infertility Camp being conducted in

Kannur in association with Mathrubhumi, she took one day leave from her office to attend

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that. The camp gave awareness on the topic of Infertility and explained about the different

treatments available and where. “They showed a statistics that told the success rate that the

hospital had in successfully implementing fertility treatments. We enquired about the hospital

later and learned that it was very famous for such treatments. Then we decided to visit here”.

G has been in treatment in the current hospital for almost 6 months. Several tests were

conducted but a specific issue was not diagnosed other than the weakness of uterine walls.

The problem that G had was due to the age. Even though all tests gave a satisfying result,

treatments for infertility was a difficult task to be fulfilled for someone in their 40s.

Medication along with diet plans and daily exercise methods were prescribed from different

professionals for G. G was person who had strict diet routines in life. As she shared, “I could

not eat so much because put on weight never suited my job. I had to wear my uniform each

day so that made me conscious about whatever I ate and how much.”

G had a family which was caring but she never wanted someone to support her. G believed in

having a space where nobody other than her husband found a place in. “Even parents must

have a limit in intruding into their children‟s lives” is what G told when asked about support

from family. Family was always something that G gave respect to but did not wanted it to be

mixed up with the problems she was going through. G never wished to share her worries with

anyone other than her husband. G and her husband lived a very simple life where friends

other than colleagues were not even a part of. G discussed about the treatment with her sisters

only if asked for or else she would keep it to herself.

G concentrated on to her profession more and became bold eventually as a part of what she

was doing during her job. Being a Jail Superintendent for years had somehow taken away the

soft corner she had for several things and made very bold. G never opened up to anyone, even

to her parents. G sometimes shared her issues with her husband and most of the time ignored

the pain of her heart. “Sometime we would start a conversation regarding the treatments but

eventually silence would overtake. We avoid the topic whenever possible. This keeps us away

from worrying so much”. Visiting places with her husband was the only entertainment she

wanted in life.

Social attendance was a very difficult task for G to attain during the initial days of treatment.

She deliberately avoided going anywhere else other than for office. Eventually, G stopped

caring about what people had to advice and suggest. She intentionally changed her attitude

towards people who came up with enquiries regarding why she was not able to conceive. G

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made it sure not explain to anyone about the treatment. According to her, it was not necessary

to please any neighbours or family members when it came one„s own life. G believed that

nobody could help her with it, mentally, physically or financially. So she found it pointless to

waste her time like that.

G being a much closed person never found a place to vent out her feelings or emotions. She

has never been to any counselling session. When asked about it, “I know about myself very

well, then why should I go to someone else for counselling?” was the reply by G.

G was very fond of her husband who was her only person to depend upon. Her husband who

was a PSC Office Assistant was also a person who did not have many friends but stayed close

to her wife. G made it clear to the Researcher that there was no lack of love between both of

them and her married life was a blessing when childlessness was not considered. G was as

bold as anyone ever could be but she lacked the hope of having a child in the course of the

treatment. The Researcher felt that her boldness was only a mask that she wore just to keep

away her worries and problems away from everyone.

Monthly travel from Kannur to Adoor was a real problem for G. She had nothing else to do

for this matter as G had a job in Kannur and such important treatment here in Adoor. Long

hours of travel made G even weaker but this did not affect her treatments. Since the treatment

was started as part of the camp that G attended in Kannur, there was a reduction in the money

that was needed for the treatment. Almost 40% of the total amount of money needed to do

IVF was reduced from the actual amount in G„s case. Thus financial burden was not a

problem for G. Even without that, G had a government job, so did her husband.

There was nothing such as a coping strategy that G developed over time. It was all ignoring

and avoiding situations and thoughts that disturbed her. G did not expect anyone to come

over and take away her sorrows. She wanted to face everything as much as possible. “If

things fell at places, treatment might work and hopefully conception would happen, if not I

would live like this for the rest of my live” was her reply before concluding the session with

the researcher. With a pale smile she showed that she was weary and tired of the treatments

of several years and even now if it does not happen, then sometimes it might not be meant to.

4.3.2 Case study 3(H)

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H was a 53 year old who lived with his wife in Kannur. H used to live with his parents and

only sibling in Kannur, but soon after marriage moved to a better place closer to the work

place. H worked as a PSC Office Assistant and his wife, a Jail Superintendent.

H got married when he was 40 years of age. The issue of infertility was identified after 5

years of marriage. Since then settling down in life was the only thought that remained in his

mind. Once when people started asking about having a baby, then the need to consult a doctor

arose. The first consultation was done in a hospital in Kannur itself. Normal medications

where given to ensure compatibility to conceive a child. Two years of treatment was taken

from Kannur. Later H underwent through treatments from hospitals in Kozhikode and

Payyannur. It was during the treatment at Payyannur hospital that H came across the news of

camp being conducted in Kannur regarding treatments for infertility. “We heard that an

efficient group of doctors were conducting the camp and I felt that it might be our last chance

to have a baby”. The camp at Kannur helped H to connect with the hospital and also get

reduction in financial expenses related to the treatment.

H looked like a very calm and patient man who showed acceptance when talking about

infertility issues. Even though these many years of treatment for infertility has caused much

of physical and financial burden, H showed the willingness to invest more of his time on this.

IVF was already done for one time which did not give a good result. H was willing to

continue with the treatment even after that but his wife was not. “It was she who had to go

through most of the burden. I would not force her to do anything. She must be given priority

in this case”, he shared. Financial issues did not affect him so far. He was able to manage

money according to the need.

The medications that H took as part of the treatment has made him put on weight. He was on

a diet suggested by the dietician. Managing body weight was one important factor when it

came to treatments related to infertility. Long hours of travel, waiting for the doctor and

returning back to Kannur on the same day exhausted H physically. But according to him

“nothing could hold him back”

H had a very supportive family who enquired about everything and gave advices when

needed. Since his wife was never comfortable discussing anything related to the treatment

with anyone, H never appreciated his family coming over to his house to spend time with.

Rather he would connect with them over phone calls and seek their advices whenever

necessary. H had several good colleagues but never wished to involve them with his personal

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life. H never depended upon other people and never expected anything from others and thus

he never had any close friends. H was a person who liked to spend time at home whenever

possible. He never had the habit of drinking or smoking. Thus that did not worsen his

problems.

Infertility has not affected his family life but according to him, it has made changes in his

wife. Social withdrawal was very much evident in her at first but later she deliberately took

the effort to make her presence in social gathering as a way of showing that she was doing

alright in life and not having a child never disturbed her so much. H looked worried about his

wife but was ready to be with her to extend possible. H liked to spent time with her and to

travel with her.

H spent most of his time working and made necessary visits to places and functions. H had

colleagues who had similar issues in life, but never used to ask for suggestions from the.

Since he stayed away from his relatives and family, nobody enquired so much about having a

child to him but only his parents. In some way or the other that was a relief for him. There

was a good understanding between him and his wife, which was the most important factor.

Nobody blamed anyone as H knew age was the biggest villain in their case and nothing else

to be specific. “We were not sure why doctors could not find out what really was the

problem. We kept on trying for a child and we did not get the result that was promised. This

time we are hoping for a good result.”

H shared his worries with her wife when in need. They did not talk much about the treatment

and issues as that created a disturbing atmosphere between them. Thus not talking about it

was their way of dealing with it. Even though that might not help them for so long, taking a

session on counselling was not even in the corner of his mind. “Everything could be dealt

with without someone else‟s help if we are self-sufficient” was his reply.

H was very hopeful in having a child through the treatment. He was ready to manage next

IVF in a few months. H tried to make his wife comfortable in all possible ways. “Mental

preparedness” was according to him the most necessary thing when it came to such

treatments. In the coming few years, he wished to have a child of his own and live happily

with his family.

He wanted his wife to reconnect with his parents once after all these became a success. That

was one of his greatest wishes. He knew how his wife avoided being with them was because

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of their issues with having a child. H was a very understanding husband who loved his wife

more than anything. Even then he carried the misery of not being able to give her a child.

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CHAPTER 5

DATA ANALYSIS AND

DISCUSSIONS

64

CASE ANALYSIS AND DISCUSSIONS

1.1 INTRODUCTION

Qualitative data analysis is the processes and procedures in which the qualitative data that

have been collected is moved into some form of explanation, understanding or interpretation

of the people and situations that is being investigated. Thematic analysis is one of the most

common forms of analysis within qualitative research. It helps in focusing on examining and

recording patterns or themes within the data available.

1.1 PROFILE OF THE CASES

Samples Cases Age Sex Family

Status

Education Occupation Duration

in

marriage

Duration

of

treatment

1 A 30 F Middle BSc

Nursing

__ 7 years 5 years

B 38 M Middle Engineering Engineer 7 years 5 years

2 C 28 F Middle M.Com __ 5 years 2 years

D 28 M Middle 11th

Driver 5 years 2 years

3 G 43 F Middle Degree Jail

Superintendent

13 years 9 years

H 53 M Middle Degree PSC Office

Assistant

13 years 9 years

The profile of the respondents gives a basic idea about the socio economical

background as well as the status of the treatment duration. The Researcher took 3

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samples which contained 2 case studies each. All the respondents belonged to middle

economic background. All the respondents had the minimum of a degree qualification.

Female respondents who had no job currently, used to work before the treatment

started. All the respondents were availing treatments for infertility for a period of 2

years for the minimum. This criterion was particularly adopted for the purpose of the

study.

RESEARCH QUESTION 1

How do the couples describe their experience with infertility?

o Theme 1: Couples’ experience of infertility

Reproduction is unique in many ways, and it performs a very important role in the process of

attaining satisfaction in life for many people. It is common that infertility might bring in

emotional stress and even anxiety in people. This could be due to several factors like pressure

from the family to have a child before getting too late, increasing age, financial problems, and

inability to accept the situation, common fear of medical procedure and so on. Here the

researcher gives importance to the overall experience of the couples going through infertile

phase of life and how the support system helped during the course of attaining treatments for

infertility. All the six cases responded that they were in stress at the time when they were

diagnosed with some inability to conceive a child. For some, its level increased eventually

and some others learned to accept the fact and even gradually made up their mind to live

without a child if the treatments failed to work.

There was emotional stress caused due to societal pressure. It was common that

couples showed anger when treatment attempts failed, anxiety and fear on results of

treatments and tests, feeling of exclusion when people of their age discussed about parenting,

helplessness and guilt for not being able to make the family happy and so on. The treatments

for infertility did not cause any problems in the relationship of the couples. All of the Cases

showed stronger bond between the couples once after infertility was confirmed.

Sub Theme 1 : First reaction to the news about infertility

The news about infertility was of a great shock to most of the couples. Several tests that

were conducted at the initial days determined the reasons for miscarriage or inability to

66

conceive. Three of the couples showed difficulty in taking in the tests results that showed

several issues with reproductive organs. For all those three couples it was primary infertility.

Case C states: “We wished to have a child before getting into our 30s. Even though

conceiving was getting delayed, we never expected that there would be a problem with our

body. It is common that we hear about such situations of others but when it happens to us, it

might not be digestible at first”

Case A states: “At first my worry was on how I would break this news to my parents and

in-laws. There were people waiting for us to come with happy news each day. I felt like, if

had another option other than going home, I would have taken that”

In both the cases, confronting their family members was the major issue. There were

people that they had to convince and satisfy. Even though the family members were

supportive, making them disappointed with such news gave them stress. Since Sample 3 lived

away from family, understanding between the couples was attained more easily.

Case H states: “Since we were not given any particular reason for our infertility, we

were confused if the doctor was wrong or something like this could happen at all. We did not

get a specific area where treatment should be concentrated to. Our first reaction was whether

to consult another doctor or not”

Confusion and sense of despair was the two main feelings that the couples went through at

the time when they initially came to know about the infertility issue. Difficulty in convincing

the family about the condition was another one.

Sub Theme 2: Initial support system

In most of the cases, family was the initial support system and that support lasted

throughout. Family was one reason for which the couples consulted a doctor for the purpose

of the treatment. Even though for some, there was a lot of pressure to conceive a child, the

difficulty of the situation was made clear and favorable support was provided from the side of

the family.

Case A states: “My parents and in-laws were very supportive. I used to share all my

concerns with them. I even had a friend to which I share my problems. It gave me happiness

and reduces the pressure of undergoing this treatment”

67

Case C explains: “My sister was my biggest support. She was more like a friend to me. But

the support from the whole family was very pleasing. Constant contact with them made me

feel relaxed. But we could not ask anyone for financial help. Everyone had their own

problems. Our family members too had the pressure of answering people. They never let us

know all those”

Family was the helpline for these two female respondents, but for male partners, it was often

their friends. Case B mentioned that he used to clear doubts and expected mental support

from his friends. Same was in the case of Case D.

Case B states: “It was a very common issue in Gulf. I have never felt any difficulty in

discussing about this to anyone

there in my workplace. People were more accepting because majority of the people there had

some issue or the other related to sexual life”.

Sample 3 had a different situation. They were given support from the families but they kept

their distance from them so the support was not very much visible to them. But it was evident

that the male partner still had contact with his parents and he received a mental support from

their side.

Case C avoided contacting her friends in any ways as they all got married and had children.

She felt very much disturbed on being in a conversation with them. It increased the intensity

of her worries.

RESEARCH QUESTION 2

What were the challenges faced by the couples before starting treatment for infertility?

o Theme 2: Challenges faced by the couples before treatments for infertility

Here the researcher tries to explain about how the life of the couples were before undergoing

treatments for infertility, even after knowing that there were certain complications related to

conceiving a child. All the three cases waited till they reached a mental state that they lost

hope of a normal conception. Even though they had concerns about not being able to

conceive, the two cases, Sample 1 and Sample 2 waited till there was a pressure from the side

of the family members to consult a doctor. Sample 3, mutually decided to undergo treatment

as their age was a negative factor and waiting even more felt like a bad idea.

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The couples never had any physiological issue evident before the initiation of the

treatment. But most of them were emotionally disturbed for which society was a reason.

There was constant pressure from the side of outside people for having a child before „it is

too late‟

Sub Theme 1: Physiological dimension

None among the six respondents had any physical issues before treatments for infertility.

Female respondents showed regular menstruation cycle. The only physical dimension that

might have acted negatively might be body weight of two of the male respondents. Case B

and Case D were asked to control body weight even during the treatment.

Case D explains: “I was a little obese and always thought of controlling my body weight.

Maybe it was because of the food habits I followed while being in Dubai. I could not manage

it properly. Now this became a problem when I consulted the doctor for treatment. He

pointed out that my over-weight could affect the outcome of the treatment”

Case A says: ‘Most people have PCOS that leads to infertility. That was not the situation in

my case. Physically, there were no evident issues. We had to do several tests to understand

the issue”

Couples thus did not show much of any physical issue before the treatments.

Sub Theme 2:Pyschological dimension

The main reason why the couples opted for treatments were the psychological distress they

faced due to the pressure that the culture and society gave them. Not being able to conceive

before 30s was seen as the most unpleasant thing in most respondents‟ society. The

incompatibility to embrace parenthood within the time that was traditionally been seen as the

„best time‟ by the society, made the couples anxious and less confident about themselves.

This affected their social life too. Fulfilling the dreams of the elder ones in the family was

another thing that emotionally drained the couples. They were bound to have children on time

so that the lineage would be successfully sustained.

Case C states: “My grandmother was falling sick gradually and she wanted to see my child

before dying. We did not have an answer for their question. It was then that we decided to

consult a doctor”. Even though there was enough mental stress for them because of not being

able to conceive, this wish for her grandmothers only fuelled the problem.

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This was a common trend among all the couples‟ family. Everyone demanded to see the

couples have a child which caused emotional pressure for them. It was later, after the

treatment has started that the family gave the couples a healthy support, but the phase before

that was hard for most.

Case H explains: “my wife is a very bold person. She gradually showed withdrawal from

interacting with my family and sometimes hers too just because she could not give them a

child. This affected the peaceful situation inside our family. We felt emotionally tired and

guilty because it was our fault that we waited for so long until we entered our 30s and 40s to

start taking the treatment”

Feeling of guilt was commonly seen among couples before treatments for not being able to

conceive or for not looking for treatments on time.

Sample 1 has not mentioned about any psychological issue that they have faced before the

treatment period. There was obvious pressure from the side of parents, but the main

emotionally exhausting experience that they had was during the treatment period of time.

Sub Theme 3: Social Dimension

Almost all the respondents have had sour experiences from the society while going through a

phase where they could not conceive. Most of them showed social withdrawal as an escape

from people‟s questions regarding the reasons why they could not have a child so far. The

response from the Cases shows women were more questioned by the society than men. This

could be because, female partners were always meant to be responsible for not being able to

conceive.

Case A states: “Some people intentionally waited for me to leave church on Sundays to ask

me about this every week. Sometimes it became intolerable”

This affected her social life where she intentionally shrank into a closed space of her own

privacy. While Case A was with her husband in Abu Dhabi, this was not a problem. This was

made clear by what her husband Case B had to say.

Case B recollects: “She was the one being blamed for our infertility by many people among

relatives and neighbours. This made her isolate herself from being exposed to others so

much. People did not question me so much. So my social life was not much affected”

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Case C states: “I stopped calling my friends who already had children. There were people

who asked us why we were waiting for a perfect time to have a child. We were not! We were

so desperately in need of a child. I felt like it was better to stay away from people than

answering all of their questions”

Case H states: “Even before the treatment, I had to stop spending time with my family

because my wife was not comfortable with them. It was because of the infertility issue. She

demanded attention and wanted me to be with her. This was one reason why I could not

socialize with people much”

Social withdrawal was thus not just a way of escapism. For someone, it happened naturally

while trying to focusing on something else. But most of the women were socially withdrawn

or their social life affected to a good extent. But as the treatment develops, people adjusts

with the changes and becomes capable of facing the society.

RESEARCH QUESTION 3

What were the factors influencing decision making and choice of the treatment?

o Theme 3: The factors influencing decision making and choice of the treatment

Here the researcher tries to explain how much decision making at the right time was

important for the couples for timely treatment. Decision making demanded acceptance by the

couples regarding their state of infertility.

For all the cases, difficulty in decision making regarding the treatment was one major

aspect. All the samples went for second opinions and showed a tendency in not sticking on to

the first doctor they have consulted. Initial failure or any small confusion regarding the

quality of treatment made them go for what they believed would be a better option. Thus

switching from one hospital to another was also one main act that included in the initial years

of treatment. Most of the couples who starts the treatment would expect to get pregnant

normally with the help of medication. In certain cases where that were not possible Artificial

Reproductive Techniques (ART) would be suggested. Making a decision on whether or not to

choose IVF or IUI was a challenging task for most of the cases.

Sub Theme 1: The mode of decision making

For four of the Cases, family was the medium through which decision was made. Even

though there was constant pressure from the family to conceive, it was only after a later

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period that seeking treatment was brought up as an option. Families showed great support

towards the couples seeking treatment. Sample 3 shows a difference in this aspect too. Even

though they waited for a long period of time before they took a decision, it was completely

based on their personal commitment.

Case B explains: “My wife was a nurse. Even she could not make a decision on when a

treatment must be started. We took advices from family and relatives for the initiation of the

treatment. Once the treatment was started we had an idea on what is to be done next”

This shows the difficulty in arriving at a decision at first. The couples needed a supporting

factor that did constant push to make them realize that it was high time. For most of them it

was Family that played the role.

Case C states: “My sister is a nurse. She was the one person who asked me to take treatment

immediately. Even though my family has already asked me to do it by then, it was when my

sister told me to do it that I really felt the need to do the treatment”

In this case, it was through the compulsion from her sister that she was able to arrive at a

decision. Sample 3 had to arrive at a decision on their own. They consulted doctors directly

as they felt it was not safe to wait for long as because of their age.

Sub Theme 2: The process of decision making

The couples had to go through a series of confusing opinions of several people regarding the

treatment before arriving at a decision. Many had people suggesting them to take up different

streams of medicine and hospitals at different places. Even after consulting a doctor, it was

difficult to all of the respondents to decide whether to continue with the treatment under that

particular doctor or not. This was because the treatment was time consuming and the results

demanded patience from the couples undergoing the treatment.

Case D states: “We were asked to do IVF from the beginning itself. But we tried to pregnant

normally with the help of medication. The doubt was whether the hospital was suggesting us

to do IVF because they could get good amount of money on this. People advised us on this

saying this is a real business for the hospital so taking medicines and trying would be the

better option. We did that for 2 years and now decided to do IVF. I never had the knowledge

to understand whatever was happening and when and how to take a decision. The money we

spent on the medication for 2 years was enough to do an IVF at the beginning itself, our bad”

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Delay in taking decision as well as making wrong decision created a sense of helplessness

among couples. The tendency to avoid ARTs maybe due to the financial burden it brought,

amount of physical care and rest it demanded and so on.

All the Samples had visited more than one hospital for the purpose of this treatment. they had

to switch doctors and methods of treatment because of the lack of clarity in things. So the

process of decision making followed a certain structure which had experiences that made the

couples realize what will be good for them and from where. Friends and family helped them

with suggesting best places of the treatment.

Case A states: “I went with the dream of conceiving a baby and came back losing one of my

tubes that produced eggs as the implantation took place in one of my fallopian tubes. It had

to be removed. This naturally decreased the probability of me getting a baby in future”

Such experiences would obviously affect the couple‟s decision on doing another IVF in

future. This supports the findings that miscarriage (pregnancy loss), ectopic pregnancy (when

the eggs implant outside the uterus) and bleeding, infection are some complications related to

IVF. (Martel, 2016)

Acceptance on the need for doing treatment

Acceptance was achieved when confusion regarding the treatment and the reasons behind

infertility was made clear to the couples. Samples 1 and 2 decided to consult a doctor because

of the suggestions given by either family or friends. Thus there was an external force that put

in the spark of doubt in the couples. Thus it was difficult for them to accept the situation with

ease. Some found it burdensome and thus neglected it at first. Case D was one such person.

He wanted to give his wife a good life so that getting married to a financially down family

would not be a burden for her and her family. Infertility was an additional burden for him.

Case D states: “Her parents were not very happy to marry off their daughter to a driver like

me. That was why I wanted to earn more money and look after her to convince them too.

Suddenly the news of infertility and related treatment was tough for me to accept”

This lack of acceptance disturbs Case D even after years too. He lacked clarity in the case of

his problem and how it could be tackled through proper treatment. Even though the first

thought of consulting a doctor was due to the pressure from family, getting into a full term

treatment was a decision from the side of the couples. Several tests that were conducted

before the treatment was the proof which convinced them to enter into such a treatment plan.

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It took weeks or months for some to accept that a lot of mental, physical and financial

investment will have to be made in order to go through the treatment.

Sub Theme 3: The type of treatment that the couples were undergoing currently

All the three samples started the treatment with medications alone. Proper medication and a

strict diet plan were the scheduled main aspects of the mainstream fertility treatment. Later

on the intensity of the issue is unfolded in the course of time and more treatment is altered

according to the need.

Case C explains: “Even though we wanted to have a child, we were not ready for doing IVF

all of a sudden. IVF was recommended by two doctors but we decided to continue with the

medications. Medicines were given for ovum maturation”

The female respondents had problems related to ovum production and maturation. Case A

was reported to have endometriosis which was removed through laparoscopy. Case B had

cysts which were removed and then treatment taken. Out of the three female respondents, two

of them had performed IVF once during the course of their treatment. Case A had successful

implantation of the embryo but to the fallopian tube which resulted in a situation where one

of the tubes had to be removed. It is only Case C that has not undergone IVF or any other sort

of ARTs.

Case G states: “We have been in treatment for the past 9 years. We have visited several

doctors and many hospitals. IVF was performed once. Next IVF was suggested many times by

doctors in Kannur but we were not ready to do it. Right now we are being prepared to

perform the second IVF in this hospital”

Thus none of the couples were undergoing IVF currently. Sample 1 and 3 were being

prepared for IVF whereas Sample 2 was still under medication and diet as part of the

treatment. Doctor asked them to wait for a few more months before making a decision about

IVF.

RESEARCH QUESTION 4

What re the challenges faced by the couples while undergoing the treatment?

o Theme 4: challenges faced by the couples while undergoing the treatment

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Here the researcher tries to bring out different dimensions through which the couples were

affected during the time of treatment. The physical, mental, social and financial aspects are

being mentioned in this portion. All of the couples had to make changes in their lives

according to the treatment plans. One of the female partners had to make alteration regarding

their job. Case A had to leave the job for giving extra care for the treatment. Case C had to

stop her coaching for competitive exams. But in all these cases, the male partner supported

the family at first. Later on, even they had to take long leaves for getting the best out of

treatments by staying home along with their wife. But taking long leaves happened in the

later years of taking the treatment. Sample 3 did not have such situations. Those couple had a

government job and had to concentrate in it too.

Thus making alterations in daily life must have affected their physical, mental and

social well-being. Most of them have come up with strategies that have helped them to

overcome difficulties that the treatment has created. Treatments for infertility are usually

expensive and time consuming. Even though all the respondents were from middle class

families, money management was a difficult task for some, thus creating financial burden.

Sub Theme 1: Impact of the treatment on physical health of the couples

Out of the three female respondents, only one showed nausea while taking medicine. One

female respondent was worried about the weight gain that occurred at a minimum range. One

male respondent showed weight gain due to medicines taken for increasing sperm count and

motility. Some had frequent headaches which could be a possible after effect of treatments

for infertility. All the respondents were asked to follow a strict diet to bring the best out of

the treatments being carried out.

Case B explains: “I noticed that I was gaining weight as I started taking medicines. At that

time I was in Abu Dhabi and doubted whether it was my food habits that made me gain

weight. It was later brought into attention of my doctor”

Case D already was obese and was in need of food restriction and strict just as Case B. Case

C has also felt the issue of weight gain but that did not last for long. Frequent headache was a

common problem for most of the respondents. But they were not sure whether the reason

behind it was the medications or not.

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Case G recalled: “I used to travel in bus for my job. I thought the headache might be due to

that reason. But it eventually intensified as I took medicine. I am still not sure about it. I

recently read that some medicines could give such symptoms too”

Sub Theme 2: Impact of the treatment on mental health of the couples

The state of infertility brought in a too much pressure, stress and psychological harm. Many

felt they should live up to the expectations of their family and were eager to please them.

Both men and women stated that they experienced feelings such as deep sadness, guilt,

loneliness and fear for an insecure future. Here the researcher tries to show how the treatment

has made the couples emotionally exhausted.

Stigma attached to fertility issues and impotency is comparatively higher in rural areas than

in urban. There are even chances of social exclusion that happens as a result of increase in

stigma attached to infertile condition of the couples. Ignorance from the side of the public can

cause the couples going through the situation a major psychological distress.

Case A explains: “There was a situation when I was not invited for a function in one of my

cousin‟s house. It was when my cousin was brought to her house for delivery. It might be a

custom not to call people like me because I was not able to conceive. That particular incident

disturbed me so much. It was from then I started showing disinterest in meeting my relatives.

But that habit changed after a year or so”

According to Case A, her immediate relatives understood her situation but for others, it was

not a big matter and no one cared about the feelings of people. Young people are aware about

all these and are more understanding than the old people. Most of the couples felt

comfortable when stayed away from distant relatives and neighbours.

Concern about the society

Case A states: “Nothing is more important than having a child. At first we were not ready to

tell other people regarding our treatment. So we used to come up with several reasons for

why we gave up the job. Low salary, bad working condition and so on were in the list. But

eventually everyone started understanding and the second year onwards we did not hide

anything from people”

Case D states: “Soon after I came to Kerala taking long leave, my first struggle was to find a

way to earn for living while staying in my place itself. The treatment demanded expensive

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tests and medicines. It was difficult for me to re-establish my contacts here in Kerala. Doing

that was not that easy. It helped me to get chances to work as a driver in my place itself”

Case G states: “I avoided people as much as possible during the initial years. It was difficult

for me to answer their questions and doubts. I skipped attending social meetings and visiting

relatives. Even spending time with my parents and in-laws made me disturbed. Even now I

keep my parents out of all these, but learned how to face the public. Avoid social gatherings

is not a healthy habit. I learned.”

Difficulty in facing people and being forced to answer their queries was the most

disturbing thing for most of the couples. All the three couples showed social withdrawal to

different variations. Male partners overcame that practice as they believed keeping in touch

with the friends and relatives was necessary for them. Initial years were in a sense, for female

partners, the time to adjust with the behaviour of the people around them and also accepting

the fact that an issue that needs to be treatments exist inside their body.

Concern about the family

The years of childlessness are were the real struggle for the family of the couples. Once the

treatment started there was clarity among all of them. Facing the society was on major task

that the family had to face. Usually it was to the parents that relatives and neighbours

enquired about the matter. This created pressure among the family members too.

Case C states: “Seeing my parents in pain was unbearable for me. Once the treatment

started everyone gave me more care and attention. My sister had a similar problem with

conceiving. But I was worried about my younger sister who was waiting for good alliances. I

am afraid if someone would think that the problem is with our genes”

Case H states: “My wife started avoiding keeping in contact with my family members. She

had a guilty feeling for not being able to conceive. I am sure that this would change once we

have a child. My parents understand this very easily but there are a few who blames us for

being like this”

Impact on family members depended on the way the couples dealt with the matter. The

situation would not be the same for all couples. In the case of Sample 1, there was an age old

lady who wished to see the couples have a child before her death. This gave them more

pressure and such situations might make the couples build hatred towards the family

members.

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Out of all the respondents, none had any relationship issues between them due to the

treatment. All the couples showed more patience to understand each other and took care of

each other.

Case C states: “I like to spend time with my husband. He was the only person with whom I

would visit places. We started helping each other once all these occurred”

Case B states: “Nobody could blame her alone. I am equally responsible for our issue. She

might not stress my issue to anyone. She was brought up in such a family where men were

given more importance over women. But support her more in front of others for being so

braving through the treatment. She needs to be encourage in front of people, only then she

would feel confident”

Through the words of Case B, it is sure that, women were the most targeted ones at

similar situations. The male respondents showed great support towards their wife and were

thankful for going through the problem along with them. Males were less affected by the

pressure from family as they were not targeted by them. Even if the problem was with the

male partner, family and society expected the female partner to find solution for that. Thus

there mental pressure was more for them. This supports the finding that, because it involves

an inability to achieve a desired social role, infertility is often associated with psychological

distress. He made the conclusion that infertility is a fundamentally different experience for

women than for men. (Arthur L. Greil, 2010)

Sub Theme 3: Impact of the treatment on social life of the couples

Living in a place where culture is given importance, there is a need to satisfy the demands of

the society. Same was in the case of the couples who were the respondents of the interview.

Here the researcher focuses on how the treatments for infertility affected the social life of the

couples.

By social life, it means at the work place, among the family or friends, times when

interaction with others would be expected from the couples, thus it could be a social

gathering and so on. The sub themes discuss how the society affected the couples positively

or negatively during their treatments or before. For most of the respondents there was

constant support from the side of family members. The difficulty was to make the relatives

and others understand why the treatment is being conducted and how much time it would

consume to bring out a result.

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All the three couples showed avoidance to social gathering. The majority took some

time to adjust to the questions asked by the people and to learn how to deal with it. The

couples at first had guilty feeling which affected their socialisation. Self-degradation was

another common factor seen among women respondents. This supports the findings that they

have negative feelings, low self-esteem, and low social support. Infertility is not mere

medical problem of the affected couples alone but is highly influenced by the social and

psychological conditions. (V idya V. Patil, 2017) But this eventually faded away and

confidence to face the society was achieved by the couples.

Change in the attendance at social gathering

All the couples showed poor attendance at social gathering during the initial years of the

treatment. Even though intentionally avoiding social gathering was a common practice even

before the treatment started so as to avoid questions about having a child, such practice got

increased to a great extend once the treatment started.

Case A states: “I started avoiding facing people. Some of them intentionally waited for me to

leave church on Sundays to ask me about having a child every week. Sometimes it became

intolerable”

Being a spiritual person, who found solace in God, visiting church was one major relief for

Case A. She wanted to visit church very often but this stopped as people pestered her with

such questions. It was usually age old people who wanted to know the details of her

condition. Same was in the case of Case C.

Case B states: “I had difficulties at the beginning to face people while being in Kerala. But

somehow I managed it because keeping in touch with people was necessary or else we would

be alienated very soon”

Being a person who had a job, socialisation was found to be an important factor. Female

respondents had an exception in this case. Case G was the only person with a job. Even she

found it difficult to face people but gradually that difficulty was solved. Case G was very

bold and stubborn person so most people never bothered her with inappropriate questions

regarding the treatment. But all the three couples showed improvement in attending social

gatherings. After the first year of treatment itself, they became capable of managing a

situation of socialisation.

Sub Theme 4: Impact of the treatment on financial status of the couples

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Here the researcher explains how the treatment impacted on the financial status of the

couples. Treatments for infertility being expensive and its initiation sometimes sudden can

challenge the smooth management of money. It would become a challenge if proper money

flow does not happen or additional liabilities disturb the balance maintained. All the couples

had to make some alterations in their career for the purpose of the treatment. Some had to

leave their job whereas some took long leave. One respondent was in verge of losing the job

but had to stay with his wife for the treatment. The other two male respondents took

occasional leave for travelling for almost a day and spending time to make consultation at the

hospital.

Treatment expenses did not affect Sample 3 who had a government job which paid

good amount of money. For the other two financial issue related to the treatments was only

an addition to the other liabilities.

Financial source

Money received through the job of the male partner was the main financial source for all the

couples except for Sample 3 where the woman respondent had a job.. There was no other

financial source reported by the respondents.

Case D explains: “I worked as a driver in Dubai. That was the only way through which we

could earn some money. I have been working as a driver since I was 17 years of age. I know

no other job to do”

Case D had to support his old parents, a sister and the expenses of the treatment, all with the

help of his job in Dubai. Taking a long leave affected him to a great extent.

Case B was an Engineer in Abu Dhabi and that was his source of money. Case B used to save

money monthly for doing the treatment.

Case G and H (Sample 3) were in Government services. All the respondents depended upon

their job salary and savings. Nobody was financially supported by family or friends.

For all the patients treatment was started all of a sudden without having few months of

preparation to save money. Extra savings were gradually started once after the initiation of

the treatment. There was not any extra income received for the purpose of the treatment. The

couples had to manage everything with the available amount of money. No loans were taken

to pay for the expenses of IVF and other expensive treatments.

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Case G states: “We approached this hospital through a camp that was conducted at Kannur.

So we got more than 40% reduction from the total expense of conducting IVF. That was a

relief”

All the other respondents had to pay the whole amount and also for the medications.

Financial Liabilities

Treatments for infertility are usually expensive and time consuming. The existence of other

liabilities along with the expenses of the treatment adds on to the burden. There were couples

who already had debt in the family and then had to manage money to pay for treatments too.

Case D states: “I am in the verge of a financial breakdown. I would not let my parents or

wife know that. She already has several things to worry about. My parents are old and cannot

help me earn money. I wish my wife had a job to support me financial. I will somehow

manage”.

Case D was the most affected by the financial burden among all the other respondents. Case

D had loans to be paid back, a sister to be married off and old parents who demanded medical

care. Case D had to leave his job in Dubai to stay with his wife for the treatment. He worked

as driver in Kerala whenever he got a chance. But that was not sufficient to support the whole

family and the treatments. This stress made him use alcohol which was expected to affect his

body and thus the treatment.

Case B explains: “I have the construction of my new house going on in parallel. We are in

need of a house and that cannot be kept aside. I had saved some for the treatment alone but

that might not be enough while doing IVF. House loan is a liability for me”

Managing everyday needs along with the treatment was the main challenge in front of both of

these Cases. The other two couples did not have any mentionable liabilities that affected the

treatment.

RESEARCH QUESTION 5

How does the couples, individually and together cope up with the problems related to

infertility?

o Theme 5: Couples, individually and together coping up with the stressors

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Treatments for infertility are at first seen as matters of dilemma. It is common for it to bring

confusions, disharmony, social exclusion, loneliness and so on. But in the course of time,

couples attain clarity with the problems that they are facing and gradually develop coping

strategies to be in peace amidst of all the issues. Here the researcher explains how the couples

managed the stress giving situations. Venting out the pent up emotions helped most of the

couples to deal with the situation effectively. That was one major coping strategy that was

effectively practiced. Being more spiritual was one other method.

Confrontation and avoidance was the two major aspects that could be seen as coping

strategies. Confrontation was sometimes seen as challenging for people. Even though

avoidance was not an appreciable practice, it helped couples for instant relief. They avoided

situations where they would have to confront questions. For Example,

Case C states: “I intentionally avoided contacting my friends as they already had a child or

two. I never wanted to become a matter of laughter or sympathy. This helped me to reduce

my stress”

Case D states: “I do not stay with her at home when there is no work. That is true. But that is

not because I do not love her. I want my self to be engaged in something or the other. It helps

me forget the pain”

Thus avoiding each other was also a method. This would be useful for the time being but

might result in a worse condition if the treatment does not show positive results.

Avoiding conversations that contained anything related to the treatment was the only way in

which Case G found peace with. She made herself involve more into her work and spend

time inside the house along with her husband when there was no work.

Sub Theme 1: Sharing issues with someone other than spouse

Since the family members were very supportive, five out of six respondents shared their

worries with someone from family or even friends. There was no conflict of keeping the

matter under cover.

Case A states: “I share my issues with a friend of mine. She was my most trusted person

after my husband. There issues only a woman could connect with. She helped me with

becoming more confident with the treatment and gave me hope”

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Case B explains: “My sister who works as a nurse abroad helps me with the treatment. She

is my guide and the only person who could make me relieved from the mental stress that

other people gave me”

Case B also had friends who even suggested him to take treatment from a particular hospital.

Thus his friend was his support system other than his wife. It was Case D and Case G who

never approached anyone for support.

Case D states: “I felt like it was better not to share my problems with anyone. No one could

help me with this, then why bother others? I had a few friends who helped me get chances to

go as driver when in Kerala. They were always with me since my childhood days. I cannot let

them show sympathy to me. Let this be like this for now. My sister-in-law helps us with

matters regarding the treatment. That would be enough”.

In the case of Case D it was his inability to approach someone that made him have no person

to share his worries with and not his belief that he did not need that help. But in the case of

Case G, it was her decision not to involve anyone in her issues. She deliberately kept people

away from her personal matters.

Case G states: “Neither friends nor family could help me with what I was going through.

Then why should I depend on them. I cannot change the situation with the sympathy they

show to me. I do not need that for now”

This being the situation of Case G, her husband Case H had contacts with his family for

support and care.

Sub Theme 2: Strategy developed to establish mutual support among couples

Here the researcher tries to explain the strategies undertaken by the couples to support each

other during the time of treatment. This period might make the couples mentally extinguished

and physically tired. Thus it demands some self-developed methods to bring harmony among

couples, to avoid feeling of being deprived, to lessen the pressure of being forced to avoid

breaking the family lineage, to regulate the intensity of social and self-stigma from affecting

their psychological well-being and so on. Sharing the weight of the burden and mutual

dependence is seen as strong factors that avoided problems in the marital relationship.

Case A states: “One of my husband‟s friends gives us necessary advices and gives us

constant support. I discuss every detail of the treatments with my husband. We take decisions

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in such a way. We both made sure to stay along with each other and that‟s why he took me to

Abu Dhabi. Being together helps us stay stronger”

Ensuring physical presence helped to build a strong bond between the couples. Being

available for each other from the beginning itself helped to avoid blaming one person for

being the reason for the situation. The couples made it sure to indulge in deep conversation

about their issue, its treatment and progress.

Case D states: “Getting myself involved in some activity helped me forget the worries. I

could not sit at home any time because this made me more anxious. I even consumed alcohol

because it helped me to forget things at least for some time. I never tried to console my wife

directly but I have made sure neither me myself nor any people around us blamed her for

anything related to not being able to conceive a child”

Case C states: “I wanted my husband to stay with me so that I could feel someone was there

to console me and help me with my fears. I found relief after talking to my sister. He had this

complex of bringing me to a financially down family. I make him know that the financial

situation in the house has never affected me and that I was blessed to be with him. I usually

tell how much lucky I am to live with the man I loved and still does”

Sample 2 (Case C and D) had coping methods that did not cater the needs of both at the same

time. But still they manage to support each other.

Case G explains: “Having a child would be the only solution for my problem. I am not that

worried like other couples. We are two strong people who are matured enough to handle the

situation so it is not relevant to support each other so deliberately”

Case G was not a person who spoke with openness. She was seen to be afraid of being

vulnerable and so tried her best to show a fake mask in front of others. Her husband, that is,

Case H supported her by not forcing her to be in contact with people whom she was not

comfortable with. Making for her a convenient space was his method of consoling her.

Sub Theme 3: Thought on the need to attend counselling sessions

All the three couples have gone through some kind of mental stress before and during the

time of treatments. Physical, mental, social and financial burden related to infertility, its

perception by the society and the stigma attached to it has in one way or the other affected all

the couples. But surprisingly none has attended any counselling sessions or other services that

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caters the psychological well-being of the couples. Even though all were suggested by the

doctors to attend such sessions, nobody cared to do it. Most of them seemed to be unaware

about the need and use of it.

Cases like Case D was in a lot of confusion about the treatment and how things could be

tackled. He was going through a lot of pressure as he was in the verge of a financial

breakdown. He wanted his doubts and concerns to be made clear but his belief that he was

not educated enough to understand it pulled him back. Case G was in great need of

counseling where she could open up and ventilate the locked up emotions. Even though she

suppressed her feelings for long, a room to ventilate would help her.

Case G states: “I am the one who knows the best about me. How can some stranger help me

solve my problems? I am have to find it for myself” was the reply given by Case G when

asked about her attendance at any counselling session.

Sub Theme 4: Other services from the hospital

The hospital provided genetics lab where issues related to genetics could be tackled. All the

couples were given strict diet plans by the dietician. Weight management was a major factor

that determined the effectiveness of the treatments being carried out. The hospital provided

counselling sessions which was not being utilized by the respondents.

Other than that, the hospital had the best department that provided first class treatment

especially in IVF. This was being utilized by the respondents.

Sub Theme 5: Expectation about the life in next 10 years

Here the researcher meant to check whether the couples really had hope regarding the

treatments being carried out. This question was responded with a smile by most of the

respondents where as some others showed great positive reply.

Case B explains: “Insha Allah! I will have a child in my life. I might leave my job in Abu

Dhabi and start working here. I would not be able to leave my wife and child here anymore.

It is a life I wished for and prayed for. And also, we will do the house warming of our new

house and live there”.

Case D could not think of anything like that. He wished to have a child as soon as possible

and leave to gulf for his job.

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Case G states: “I will be as strong as I am right now. If this did not work out, we will live as

how we used to in the past 13 years. Nothing is promised, live with confidence”.

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CHAPTER 6

FINDINGS, SUGGESTIONS AND

CONCLUSION

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FINDINGS, SUGGESTIONS AND CONCLUSION

6.0 Introduction

The study titled ―Lived Experience of Couples undergoing Infertility Treatment

at N Superspeciality Hospital, Adoor intends to document the lived experiences of couples

dealing with infertility. In specific, the study looks at the challenges encountered by couples

before starting treatment for infertility, the factors influencing their decision on the choice of

treatment, the challenges while undergoing the treatment for infertility, and how they together

cope with infertility treatment, the study adopts a qualitative approach and used the multiple

case study design. Couple belonging to middle class, with primary infertility, undergoing

fertility treatment at N Superspeciality Hospital, Adoor, for more than two years were

purposively chosen as units for the study. Couples belonging to middle class family. Three

couples were subject to interview using a semi-structured interview guide with 16 subthemes.

The themes that evolved were subject to thematic analysis and the findings were as reported

below.

6.1 FINDINGS

A) RESEARCH QUESTION 1: How do the couples describe their experience with

infertility?

The respondents felt that childlessness due to infertility inhibits a person‟s capacity to

fulfil their biological role of parenthood. This brings in stress, anxiety, fear,

frustration and feeling of guilt for not being able to give birth to an offspring. Couples

usually consider this situation as a personal failure and as a very tragic experience.

Thus the initial reaction of the couples to the news of infertility was shock and

unbearable sadness as they knew that they have to undergo long-term and very

expensive treatment in the future.

The respondents had immense family support during their initial stage of diagnosis. It

was this support that helped them survive through this difficult time in their life. None

of the partners faced any discrimination or bad remarks from their family members

based on their diagnosis. But there was pressure from their family to undergo

treatment in order to secure the family lineage. The couple‟s parents also experience

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difficulty during this phase as they had to answer others, enquiring about the reasons

for the couple not having a child.

The couples took weeks or even months to accept that they needed to undergo

treatments for their infertility issues. All the couples went for second and sometimes

third opinions, to make sure that it was not an error in diagnosis. They easily moved

from taking consultation from one doctor to another in their desperation to conceive.

B) RESEARCH QUESTION 2: What were the challenges faced by them before

starting treatment for infertility?

There were certain biological factors such as age, low sperm count, irregular

ovulation, and removal of fallopian tube that led to infertility in the participants. They

did not have any visible physical issues as such. Therefore, the diagnosis came as

shock to the couple.

Not being able to embrace parenthood even after several years of married life caused

frustration and emotional distress in couples. They felt helpless and sad as they never

expected that they would have to undergo treatment to have a child. They found it

hard to accept this fact. This was the major challenge for them.

Facing the public was another challenge in front of them as they were constantly

asked about their plans of having a child, but they had no answers and did not know

how to respond to this question. The female partners faced more difficulty in

socialization compared to the males as they felt that the society would perceive it as

their inability to conceive a child and would find fault in them. They had to face more

questions on this aspect than the males, hence they avoided going out and meeting

others. Males were comparatively adaptive to the situation and were less preyed on by

others.

C) RESEARCH QUESTION 3: What were the factors influencing decision

making and choice of the treatment?

Even though the couples were desperate to have a child, they wanted to wait and try

to conceive naturally even after the diagnosis, but constant pressure from their family

and friends to undergo treatment, coupled with questions from others, forced them to

undergo treatments for infertility.

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The couples also knew other couples undergoing treatment for infertility, their

experience with infertility and treatment for infertility instilled hope in the participant

couple to try their luck in treatments for infertility. The support and experience

sharing from other couples with similar experience also influenced their decision.

Over a period of time, the couples accepted their condition and they mutually decided

to go for the treatment. They knew and mutual acceptance on the fact that treatments

for infertility required time and sheer dedication from the side of both the partners.

Proper communication, mutual understanding agreeing on responsibilities helped the

couples to take the decision to undergo treatment.

This particular hospital was chosen by the participants based on the suggestions they

got from their friends, they were hopeful after learning that this hospital had a good

success rate. The couple‟s choice of treatment depended on the advice of the doctors

based of their physiological conditions.

D) RESEARCH QUESTION 4: What are the challenges faced by the couple while

undergoing the treatment?

The couples underwent treatments like taking in medications, administered with

hormone injection, Intra Uterine Insemination (IUI) and In Vitro Fertilization (IVF).

One of the participant experience ectopic pregnancy which had to be surgically

removed. Weight gain was one major side effect of medications and hormone

injections taken as part of the treatments for infertility. Another common issue was

persistent headache. Female respondents felt nauseous while taking medications.

Strict diet was recommended for the couples to maintain body weight, for the

treatment to be more effective. The initial years of treatment was found to be the most

challenging time as the couples had to adjust with the treatment procedures and

drastic change in their lifestyle that was made as a part of the treatment. Counselling

was recommended to the respondents as the doctors believed that counselling would

help them to make their decisions appropriately. But none of them availed the service.

The female partners had to leave their job as the treatment required them to adhere to

strict diets and lifestyle changes. Travelling was also discouraged by the doctors.

Meanwhile the male partners supported the family. One or both of the couples had to

make some kind of alterations with respect to their job. This affected the money flow

and the expensive treatments made the situation even worse. Medications were

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expensive and for doing ARTs, no amount less than with a 6 digit number was

demanded. Couples with a steady income and saving were least affected whereas the

couples with family debt and other liabilities faced major financial burden. In the

respondents with financial liabilities there was a tendency to intentionally avoid IVFs

because of the extra financial burden it put them in along with the existing liabilities.

The Couples with financial issues wanted the treatment to end as soon as possible and

showed helplessness more than hope. This caused stress in the couples.

The couples experience social stigma as well self-stigma associated with infertility.

This was more evident in the case of the female respondents. Even during the

treatment they had to deal with others perceiving infertility, as a women‟s fault. They

felt that no matter what the reason is, people always blame the women and it has been

going on from time immemorial. Even though they were undergoing treatment they

opted to stay away from social gatherings as much as possible to avoid such questions

and also because they considered themselves not presentable in front of others. They

would consciously avoid talking to their friends with children or socializing with

others outside their family. Male respondents found it easier to socialize with others,

major reason behind this was that they were not usually asked questions pertaining to

having children or their condition or regarding the treatment. Stigma attached to

fertility issues and impotency also created emotional distress in couple.

E) RESEARCH QUESTION 5: How do the couples, individually and together

cope up with the problems related to infertility?

Being spiritual helped couples manage the mental stress. Some people “confronted”

the problem and accepted their condition whereas some “avoided” it. Avoidance was

practiced for instant relief.

Ventilating pent up emotions was one major strategy adopted. Couples found solace

while sharing their feeling with people other than their spouse. It helped to achieve

guidance from a person who was not biased or was under too much pressure because

of the treatment, which, their spouses sometimes was. Family played a main role in

being the helpline for the couples. Family worked as a protective shield which gave

the couples a place to remain safely without being affected by the external pressure.

The couples who were close with their family in sharing their issues were found to

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adjust and accept the situation more easily and effectively. Couples with good support

system showed great optimism regarding the treatments related to infertility.

Mutual support was established by ensuring each other‟s presence while being under

treatment. Male respondents made it sure to avoid their partners from being judged,

excluded or discriminated on the basis of the infertile condition they were having.

They shared the burden of the infertility and supported and sympathized with each

other. The ones with mutual understanding and good communication between both

the partners experienced lesser stress.

6.2 SUGGESTIONS

There must be a mandate to provide counselling to the people who come for treatments

for infertility. They must be observed keenly by the Counsellor for the purpose of

understanding their need and guiding them towards bringing psychological well-being

during the time of treatment. Good mental health would increase the effectiveness of the

treatments.

Social workers must be made to work along with the counsellors to help the couples

overcome self-stigma and to educate the public to avoid social stigma.

The general public must be made aware of factors causing infertility, and measures that

can be taken to avoid it such as adopting a healthier lifestyle, reducing stress, maintaining

normal weight, by preventing sexually transmitted diseases etc.

Social support system must be strengthened. There must also be a way to educate the

immediate relatives of the couples undergoing treatment as a way of training them to

accommodate and support the couples in their journey of conceiving a child of their own.

Educating young ones is necessary not only about ―Reproduction and Health‖ but also

about ―Inability to Reproduce‖. Childlessness is an importance area needing attention as

much as population growth in a developing country.

Adoption could also be encouraged by the doctors once the treatment is found to be

unsuccessful rather than putting financial strain on the couples, which could lead to

mental stress.

There must more camps conducted by hospitals in order helped poor people to get access

to such treatments for their issue of infertility. Providing free medicines and reduction in

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ARTs expenses should be promoted. Government level policies can be helpful in

providing such services.

6.3 CONCLUSION

Childbearing is considered a major milestone in a couple‟s life by which their worth is

measured and their family lineage is secured. Hence infertility bring with psychological

distress as well as social stigma. It is time we recognize it as a condition with physical,

mental, psychological and social implication. This study aimed to understand the lived

experiences of couples undergoing treatments for infertility. The findings of the study

indicate that the couples undergoing treatment for fertility had to deal with social, physical,

and psychological problems before undergoing treatment. They had to face all these problems

along with financial burden as part of them undergoing the treatment. The couples did not

considered themselves as needy of treatments until the negative pressure from family, the

wish to grow up to the expectations of people and their desire to embrace parenthood came

into play.

Various coping strategies were adopted by the couples, individually and together to help them

though this phase. This included confronting the problem or avoiding it. Mutually supporting

each other and ventilation of feelings to their spouse, family and friends was another strategy

used. It is important to provide counselling to the people who come for treatments for

infertility. More provisions must be brought in to help poor people to get access to treatments

for their issue of infertility. Providing free medicines and reduction in ARTs expenses should

be promoted. Government level policies can be helpful in providing such services.

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CHAPTER 7

REFERENCE AND

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APPENDIXES

TOOL FOR DATA COLLECTION

As this is a qualitative research the researcher decided to conduct semi structured in depth

interview using a semi structured interview guide. Data was collected from 8 respondents and

the interview was done on the basis of the research questions. There were 5 research

questions and 16 interview questions that supported the research question which guided the

interview.

Age:

Sex:

Educational Qualification:

Family Status:

No. of Family members:

Occupation:

Duration in marriage:

Duration of availing treatment for infertility

Couples’ experience of infertility

• What was the first reaction to the news about infertility issues?

• What was your initial support system during that time?

Challenges faced by the couples before treatments for infertility

• What were the physiological challenges faced?

• Were you psychologically disturbed before the treatment?

• What were the social challenges faced before treatment?

The factors affecting the decision making and choice of the treatment

• What was the mode of decision making?

• What was the process of decision making?

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• What is the type of treatment that you are undergoing as of now?

The challenges faced by the couples while undergoing the treatment

• How was the couples physically affected during the time of treatment?

• How did the treatment affect the mental health of the couples?

• How is the financial status of the couples affected due to the treatment?

• In what ways the social life of the couples was affected by the treatment?

Couples, individually and together coping up with the stressors

• To whom do you share your things with usually, other than your partner?

• What strategy do you take to support your partner?

• Have you ever felt the need to have a counselling session?

• What are the other services that you receive from the hospital?