Nearly 5% of new-borns in the Netherlands are now born following Medically Assisted Conception (MAC), a steadily increasing number. Our qualitative study explored the subjective impact of subfertility and fertility treatment for parents who successfully achieve pregnancy following MAC and make health professionals more aware of the psychological needs of those clients. The study was based on the constructive/interpretative paradigm using a constant comparison/grounded theory design. Two men and nine women in the Netherlands who conceived as a result of MAC were interviewed in 2011. Our findings show that MAC-parents were exposed to a range of emotions such as disappointment, hope and uncertainty during the subfertile period, and these feelings were even felt after successful fertility treatment. The relationship and social support from friends and others in the same position were very important. Regarding the relationship with the partner during the subfertile period, the main thing the couple have to do is to keep talking with one another. Although they did not always agree on all issues, it was found that maintaining the communication strengthened the links between them by the end of the process. We concluded that the feelings and emotions during fertility treatment play a big role during the subfertile period and remain important during pregnancy and even after childbirth. Subfertile clients want maternity care providers to ask those who successfully achieve pregnancy following MAC about their experiences during fertility treatment, check that they still are receiving adequate social support, and involve the partner in prenatal checks.
The current prevalence of subfertility (not being able to get pregnant (conceive) after one year of regular, unprotected sex) is estimated to be around 9% worldwide for women aged 20 - 44 [
Subfertility and subsequent fertility treatments in general can have strong negative psychosocial consequences, although Paul et al. [
The pervasiveness of the psychosocial impact of subfertility and fertility treatments, has led some authors to concluding that midwives and other maternity care providers need to know about their clients’ experience during a possible previous period of subfertility if they are to plan perinatal care effectively [
The research question addressed in the current paper was: How do parents after a MAC-assisted pregnancy describe the psychosocial impact of the subfertile period and fertility treatments? The aim is to make health professionals who provide midwifery care for people who have conceived with MAC more aware of any specific psychosocial need they might have as a result of the experience of infertility and fertility treatment.
This qualitative study was undertaken using an interpretivist/constructivist paradigm and a constant comparison/grounded theory design [
The participants―who have conceived and given birth as a result of fertility treatment- were recruited via an announcement on an internet forum for people with fertility problems and via snow-ball sampling. Nine interviews with eleven participants were held. Two couples were interviewed at home in Groningen in the spring of 2011 by final year midwifery students (student group A) who had received a five-day training on interviewing and qualitative research. After the decision to continue this study, seven interviews with participants outside Groningen were held by phone by CW (psychologist) in November 2011. All interviewees had gone through a period of subfertility and finally became pregnant after fertility treatment. The interviewers did not know the interviewees. There were two other persons interested in participating in the study, but they dropped out for unknown reasons before the interviews were held.
Prior to data collection, the topic list and semi-structured interviewing method were tested in a pilot interview with a midwife lecturer. The topic list shown in
Fertility history (context of desire to conceive, fertility treatment, gravidity, miscarriages, surrogate pregnancies, abortions) |
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Gynaecological & obstetric history (parity, details of past pregnancies) |
What was your experience during your period of subfertility? |
What role did feelings and emotions play during the period when you were trying to become pregnant? |
How did the people close to you react to your feelings and emotions during fertility treatment? |
an interview the interviewers evaluated their findings and formulated areas that called for more in-depth exploration in the next interview related with the current study, following the constant comparison/grounded theory design.
All nine interview recordings were transcribed verbatim. The transcripts were initially read separately by JM, NM and CW and text segments were selected on relevance to the research question. Data were then categorized into themes by each researcher, using content analysis [
This study was approved for research purposes by the scientific committee of our institute (WC2011-005) and supported by patient organisation Freya. All interviewees received written information by email and verbal information about aim and content of the interviews, and the interviewees gave verbal informed consent to audio taped interviews. All participants were assured of anonymity and confidentiality and that they could freely withdraw from the study at any time. All data were anonymized. Each participant was given the opportunity to read their transcript and a draft version of this article. No further comments were returned.
We held interviews with participants from different parts of the Netherlands (north, central, south).
1st level | 2nd level | 3rd level | 4th level |
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Fragment | Labelling | Category | Theme |
Bertha p.4.: “Such a range of different feelings. Angry one moment, sad the next, and finally indifferent-you just say, well that’s how it goes. (..) A bit of an emotional rollercoaster.” | Angry Sad Indifferent Emotional rollercoaster | Feeling and emotions with MAC | Emotions during MAC |
women was 34.1 years (range 32 - 38 years) and the average age of the men was 33.5 years (range 32 - 35 years). The majority of the participants had waited two years or more to get pregnant (range 6 months-5 years). The cause of subfertility was attributed to the woman (n = 2), the man (n = 4), both partners (n = 1) or cause unknown (n = 2). Different fertility treatments were used, like IntraUterine Insemination (IUI), IVF, ICSI and donor insemination (DI).
The perceptions on psychosocial aspects of subfertility of parents who have conceived and given birth as a result of fertility treatment could be categorised into three main themes.
1) Emotions during MAC, describing the feelings and emotions associated with fertility treatment, motherhood and getting on with life after fertility treatment.
2) Social environment, describing the interaction with friends and relatives with other pregnant women and their children, and with others in the same situation and the hospital.
(Fictional) name | Age1 | Region | GPA2 | Cause of infertility | Type of fertility treatment3 | Duration of treatment | Care provider during pregnancy |
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Anna | 33 | Groningen | G1P1 | Reduced sperm potency | ICSI 5 attempts in the cycle and 3 replacements | 2.5 years | Midwife referred to gynaecologist at term |
Abraham | 35 | ||||||
Bertha | 31 | Groningen | G1P0 | Early menopause | 7 IUI 6 ICSI in own cycle Hyperstimulation | 4.5 years | Midwife |
Bjorn | 32 | ||||||
Catharine | 37 | Utrecht | G2P1 | Cause Unknown | 1st: 4 IUI, 2 IVF, 1 cryo replacement 2nd: spontaneous | 4 years | Midwife referred at 36 weeks Midwife |
Didi | 34 | Overijssel | G2P0A1 | Reduced sperm potency | 4 ICSI in Zwolle and 1 ICSI in Germany | 4 years | Midwife |
Erica | 32 | Zuid-Holland (Leiden) | G2P2 | Cause unknown | 1st: 5 IVF, 7IUI, 2 ICSI 2nd: 12 cryos, 1 ICSI | 1st: 4 years 2nd: 1.5 years | Midwife Midwife |
Fay | 38 | Utrecht | G2P2† | Male infertility | 1e: TESA premature labour at 23 weeks: delivered by midwife 2nd: finish up Cryo , 2 x ICSI | 1st: 1.5 years, 9 months on waiting list 2nd | Midwife referred at 23 weeks Gynaecologist |
Gwen | 36 | Utrecht | G3P2†A1 | Elevated FSH, otherwise unknown | 1e: spontaneous IUFD at 24 weeks due to trisomy 18 2e: spontaneous 3e: 7 IUI, 1 ICSI | 2nd: 6 months 3rd: 5 years | Midwife referred to gynaecologist at 6 months |
Helen | 34 | Overijssel | G2P1A1 | Sterilization of husband | 1st: PESA, 3 ICSI 2nd: 1 ICSI | 2.5 years | Midwife |
Ivonne | 32 | Noord-Brabant | G2P1A1 | PCOS Male infertility | 1e: 6 ICSI, 3 cryo, 1 IMSI in Germany 1 DI (IUFD 10 week) 2e: 1 DI | 4.5 | Gynaecologist |
1At time of interview, 2G = gravidity, P = parity A = No. of abortions, 3Cryo = cryopreservation, DI = donor insemination, ICSI = intracytoplasmic sperm injection, IMSI intracytoplasmic morphologically selected sperm Injection IUFD = intrauterine Foetal Death, IUI = intrauterine insemination, IVF = in vitro fertilization, PCOS = polyCysteus ovarium syndroom. PESA = percutaneous epididymal sperm aspiration, TESA = testicular sperm extraction.
3) The couple’s relationship, describing the importance of communication, the importance of reaching agreement on key issues and the partner’s perception of the whole fertility treatment process.
Fertility treatment gives rise to a variety of feelings and emotions to the interviewees, irrespective of the type or length of fertility treatment involved. The interviewees experienced MAC as time-consuming and frustrating (
Anna (p. 2): “You know in advance that it’s not going to be an enjoyable experience, and you take that into account, but still … all that waiting, the whole process takes so long, it’s just very frustrating.” Anna (p. 13): No, I don’t think I really felt like that. Of course, it’s disappointing but you develop immunity to disappointment.” Bertha (p. 4): “Such a range of different feelings. Angry one moment, sad the next, and finally indifferent―you just say, well that’s how it goes.” |
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built up. In brief, the parents experienced a whole range of conflicting emotions during the subfertile period (
Nevertheless, motherhood seemed to be so important for all women that none actually stopped treatment. One of the reasons was that motherhood is such a basic instinct to these women that they cannot imagine life without it (
Sadness was followed by frustration, when interviewees found that they could not plan for the future. Participants found in very difficult to make practical decisions, because they did not know what their life would be like in the future (
Couples who were prepared to talk openly about their fertility treatment received a lot of social support and involvement from the people around them (
Interviewees sometimes found it difficult to deal with the pregnancy of their friends who had conceived naturally (
The contact with people in the same position through Internet forums or in their own social network, and the recognition and understanding this gave, was particularly welcome (
Erica (p. 22): “Yes, it’s a kind of basic instinct, I think, the wish to have a baby whatever happens.” Catharine (p. 17): “The possibility that increased with every course of treatment you had―at least, that’s how you feel-that you would never have the baby you dreamed of. I really couldn’t imagine a life without motherhood. It was like a huge monster creeping up on me, and it would leave a big black hole behind: I couldn’t imagine what would happen if we were in that situation.” Erica (p. 21): “It’s such a big part of your life, isn’t it? I just couldn’t be without it.” |
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Catharine (p. 15): “At a given moment I needed to make up my mind about study, work and all those sorts of things. But it’s impossible to make decisions if you don’t know what’s going to happen in the years to come.” |
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Bertha (p. 3): ‘’ We always spoke very openly about it to everyone―even my boss, or colleagues. You simply need to say, we’ve just got back from the hospital. Being perfectly honest with everyone is definitely the best course of action.’’ |
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Didi (p. 4): “But then, suppose your friends manage to get pregnant. That can be really difficult to deal with. Of course, you’re glad for them, but you’re longing to be in the same position yourself. And you see a big change in them: they’re going to be parents, they’re going to have a baby, and they’re moving on to a whole new phase in their life.” Bjorn and Bertha (p. 5): “She said she was pregnant, and the baby was giving her trouble. Well, you wish your friends would shut up about that kind of thing. I mean, it’s not very tactful to say ‘Oh, the baby’s giving me such terrible lower back pain’ when you know that I’m thinking I’d give anything to have lower back pain if I knew that I would be expecting a baby at the end of it.” |
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Ivonne (p. 15): “One thing I particularly appreciated all those years was being on a forum that brought me into contact with all kinds of people in a similar situation. I was very glad of the understanding these other people showed. (...) We were all in the same boat. I was always very glad to be able to talk about it.” |
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and sometimes engendered more trust in the treatment. The others were ‘experts by experience’ and could give good advices about treatments, etc.
One interview underlined the support and understanding offered to the couple by hospital staff. They were ready at all times to do what was needed, not only for the woman but also for her partner (
A recurrent theme in the interviews was that the couple went through the fertility treatment together, and shared various feelings and emotions in the process (
It was important for couples to discuss their different views of the treatment and to try
Ivonne (p. 15): “They also always explained everything they were doing in great detail. This emphasis on the procedure gave me a lot of confidence in the treatment, and they always asked how I was doing, and they asked my husband too. You don’t get that degree of attention everywhere, so I always appreciated the fact that they were like that at the hospital in Breda.” Ivonne (p. 5): “I really got a lot out of it. I went to see her every 6 to 8 weeks or so, and she always laid her fingers on the painful points as it were, and on the things I was unconsciously concealing a bit.” |
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Abraham (p. 4): “I always had the feeling that we experienced everything as a unit. Of course, the physical aspects really only concerned her, but we had agreed to do everything together as much as possible, so even when she was being treated I was always there.” Didi (p. 4): “As long as you have the same targets in your sights, as long as you say we’ll do everything together, everything possible, that unity gives you strength.” |
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Bertha and Bjorn (p. 5.): “I have noticed that you experience the whole process differently from me and I experience it differently from you; and then the assumptions we make, you know … you have a great tendency to say she’s sad, I’m sad so she must be too, these processes don’t run in parallel.(..) And then again, the same emotion can be expressed in different ways.” Didi (p. 4): “If one partner sets a limit and says I’m going to stop after five treatments for example, then you’ve got a problem in my opinion. I really had to work hard to get my husband to come to Germany with me. For the fifth treatment session, because he’d really had enough by that time.” Catherina (p. 15): “Well, you know, these treatments are often more of a woman thing than a man thing.” |
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to reach agreement on this point. In many cases, the two partners expressed the same emotion in a different way, and then it was important to reach a common expression of these emotions (
A majority of partners always accompanied the woman to a consultation. Feelings of powerlessness during the treatment were often expressed. The partners did their best to understand what was going on during the treatment (
The present study was aimed at exploring the perceptions of the psychosocial aspects of subfertility in retrospect by Dutch parents who achieved a successful medically assisted conception. There is a psychological legacy of the experience of infertility and infertility treatment which can make people psychologically vulnerable during pregnancy and after birth so heightened awareness of this among maternity care providers would be welcome.
Fertility treatment for our participants was associated with a range of negative emotions, which is consistent with earlier literature [
Bjorn (p. 6): “Well, I was nearly always there too, I went with her. You can’t do much, but at least you’re there. But it’s not my body. That’s even more the case than in a pregnancy. There too, you’re just standing around with nothing to do. (..) You can try to understand what’s going on, to follow the procedure, but sometimes you simply can’t. Especially when they inject those hormones, I sometimes have absolutely no idea what’s going on. Then you may have to say, I don’t understand why, but they’re giving her hormones.” Erica (p. 20): “He hated to see me suffer like that. (..) You could see him thinking, I just want it to stop. For your sake as well, but simply because … It’s just so terrible.” |
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participants described positive emotions that could occur, especially hope. It seems that particularly the alternation of hope with disappointment and stress is what makes the fertility treatments so emotionally taxing. The women involved also lose much of their self-confidence, and feel that they can no longer trust their own body. Couples and women were exposed to a whole range of emotions during the subfertile period, and these feelings were even felt after successful fertility treatment. The feelings and emotions which played a role during the subfertile period and fertility treatment might be only incompletely resolved and thus persist for many years, even after pregnancy.
Our analysis showed that the women we interviewed regarded motherhood as a kind of basic instinct and they could not imagine life without children. This may be one of the reasons why none of our interviewees decided to stop their treatments. This influence of the idea of motherhood on the perception of subfertility concur with the review by Greil et al. [
Like ESHRE [
One woman from our study consulted a medical psychologist and found this very helpful. Boivin, et al. [
Similar to the findings of Wirtberg et al. [
One of the strengths of this study is its originality. To the best of our knowledge, this study is the first to explore the clients’ perception of subfertility following successful assisted conception in the Netherlands, where a MAC pregnancy can be monitored by midwives in primary care. We believe that the interpretative/constructivist paradigm as frame of reference is appropriate to our research question. Our study explored the subjective perception of subfertility following assisted conception. We let the parents who have conceived and give birth as a result of fertility treatment speak about delicate issues. To increase the credibility of our findings, we used diverse researchers (investigator-triangulation), a varied group of participants (negative case analysis) and we conducted both individual interviews and interviews with couples letting these two methods complement each other. Particularly delicate topics might be more readily discussed in individual interviews covering maximum depth, whereas for other topics this might be the case in an interview with couples, where there is a more dynamic interaction between the couple and this can generate new ideas or evoke new insights that might not have come up in a one on one interview (data-triangulation). We maintained an audit trail in which we indicate with whom we had a conversation and about what or whether there were any special circumstances. The final subthemes and main themes were discussed in a group session of health care professionals at a conference, and with a midwifery consultant at a fertility centre and with midwifery lecturers (peer debriefing). Participants checked intermittent results of the study (member-checking). Transferability was established through “thick description” [
Despite these strengths, limitations need to be taken into account. The main limitation involves the small sample in which particularly men’s perceptions could not be investigated fully. The small number of the joint couple interviews might restrict the impact of the study for the research field. Nevertheless, usable results were obtained that were in agreement with the findings of other authors. Another limitation might be that participants had undergone a wide range of fertility treatments, with no acknowledgements that more invasive forms of treatment or the number of treatment cycles, may have affected the perception of the psychosocial aspect of subfertility. In addition, there are disadvantages related to the use of telephone interviews. However, given the wide variety of perceptions captured, we believe that this had no significant influence on the results of this study. Memory biases may have affected the research findings, due to the retrospective nature of the study and the positive pregnancy outcome reached by the participants. The recruitment strategies (through internet forums and snowball sampling) may have also influenced the findings, reaching participants who may be more motivated/comfort
Like Gameiro, et al. [
Subfertility and fertility treatment are intensive life events that are associated with many different feelings and emotions. It is advisable to take this into account during the antenatal and postnatal care of women who have undergone fertility treatment, and to devote extra time to their emotional well-being during pregnancy and the immediate postnatal period. the theme Emotions during MAC highlight that participants experienced negative emotions but also strong emotional shifts (with positive emotions) at different stages of the subfertility period and a sense of uncontrollability toward the future. As such, primary care midwives may need to provide psycho-education to clients during preconception counselling, about the emotional experience at different stages of the subfertility period, promote realistic expectations toward subfertility treatments and discuss strategies that can help clients to deal with the sense of uncontrollability toward the future. The specificities of each client (namely, the meanings attributed to parenthood) need to be taken into account in clinical practice, because it could influence the subjective experience of subfertility.
Given the importance of social support to our participants, we recommend that midwives and other maternity care providers should check thoroughly whether their clients received sufficient social support during fertility treatment, and whether they are still receiving such support during and after pregnancy. If necessary, the maternity care provider could suggest that clients visit relevant internet forums. Fertility treatment can have various effects on the woman’s relationship with her partner and our participants emphasized the involvement of the partner in the treatment. It is therefore advisable for the midwife or maternity care provider to also involve the partner in prenatal checks. Couple communication, emotion sharing and shared decision-making can facilitate the psychosocial adjustment of the couples to subfertility period and may be enhanced by healthcare providers. Further prospective research could be aimed at investigating the male experience of subfertility or conducting other joint couple interviews in order to provide an in-depth analysis of couple dynamics/processes and gender issues related to the subfertility period.
Our study confirms that the feelings and emotions that play such a big role during the subfertile period remain important during pregnancy and even after childbirth. They do not disappear when the woman has achieved her heartfelt ambition of having a baby. It may thus be concluded that fertility treatment has a big impact on people’s life. Participants want midwives or other maternity care providers to ask those who successfully achieve pregnancy following fertility treatment about their experiences during fertility treatment, and also want them to check that they still are receiving adequate social support.
The authors are indebted to the participating parents with a history of subfertility and the patient organisation Freya. Furthermore, we would like to thank the students of the Midwifery Academy Groningen group A (Lilian Alberts, Daniëlle Bouma, Simone Brandt and Joske Huitema) for interviewing two couples, and group B (Amanda van der Wal, Irma van der Meer, Annette Zijlstra and Indira Rojer) and group C (Rianke van der Maas, Milou Pijper and Francis Strating) for their earlier contributions on the subject. We would like to thank INholland for receiving the Research award.
CW originated and supervised the study, was responsible for gaining ethical approval and recruitment of participants. CW interviewed 7 women. JM, NM and CW analysed the data, assisted by SM and MvL and drafted the manuscript. All authors read and corrected draft versions of the manuscript and approved the final manuscript.
The authors declare that they have no competing interests.
Warmelink, J.C., Meijer, J.M., Mulder, N., Mulder, S. and van Lohuizen, M.T. (2016) Perception of the Psy- chosocial Aspects of Subfertility by Parents Following Successful Medically Assisted Con- ception: A Qualitative Study. Open Journal of Obstetrics and Gynecology, 6, 830-845. http://dx.doi.org/10.4236/ojog.2016.613101