Qualitative Study of Women's Experiences with In Vitro Fertilization in Maybod City

ORIGINAL ARTICLE Background: In vitro fertilization (IVF) is one of the most important treatments of infertility for couples. The purpose of this study was in vitro fertilization experiences of women in Maybod city. Methods: This study is based on the qualitative approach and Grounded theory method. Under-study populations were infertile females of Maybod City. Cases of the study were 14 women which were selected with purposive sampling up to data saturation. Data of this investigation were collected from semi-structure interviews. After data collection, open, axial and selective coding was performed. Results: After the first step of coding 348 primary codes were collected and they categorized into five main groups including turning to spirituality, keeping the stability life, overcoming on mutual challenges, mental occupation, and common acceptance. Conclusion: According to the findings of this study, for women with several unsuccessful experiences of IVF, the main problem related to their infertility is unstable family.


Introduction
Infertility is a biological phenomenon that has different cultural, social and psychological dimensions. Fertility and reproduction has an important role in different cultures and human societies. Infertility is one of the biggest challenges in traditional and non-traditional families which sometimes lead to remarriage or divorce. 1 This problem is even more challenging for women, because in different cultures women are symbols of reproduction and fertility. In most of the times especially in some traditional cultures and small communities, there are more cultural pressures for women in comparison with men. Infertile women are more stigmatic and there is a more probability of experiencing social pressures for them in their families. According to these problems, women are going to recover their fertility ability. Some superstitious beliefs affect the families and they will increase the probability of divorce. 2 In medicine infertility is considered as an inability to be pregnant, after one year of intercourse without contraception. According to the international statistics, there are about 60 to 80 million infertile people all over the world. 3 In Iran the statistics of infertility is more than their worldwide average level with the17.3 percentage of infertility. 4 Male infertility is responsible for 40% of infertility cases, while 40% of infertility cases are due to female infertility. 10% are related to both of couples. 10% of cases, are due to unknown causes. 5 infertility has different social psychological and economical outcomes for couples and their family. It seems that infertility is one of the most important social experiences especially for the women. Infertility leads to some undesirable outcomes which finally result in some mental problems like depression and anxiety. In addition, 10 to 12% of women experience secondary infertility which comes through after some women's reproductive illnesses after their first childbirth. According to this problem the number of the women with fertility inability is going to be increased in comparison with men. In addition, with the increasing of the age, the percentage of the infertile women is going to be enhanced. 6 Infertile persons are more unsatisfied with themselves and their marriages which finally lead to their social retirements. They would experience more pressures and challenges in their social and marriage interactions. The experience of infertility which is called infertility crises he's come up with some physical, social, and psychological pressures, which finally influences on different aspects of people's life. These effects finally result in reduction of sense of sincerity, self-confidence, satisfaction of marriage with the feeling of social exclusion and fear of separation. 5,6 With the developments of technology, now there are different methods for treatment of infertility for men and women. Among the different methods for treatment of infertility, there are some of the couples which are paying attention to in vitro fertility (IVF) as one of therapeutic strategies. Although most of the times there is a high motivation for a couple to do this treatment but this approach is not always with success. The method of IVF is a fertility exterior of the uterus. In addition, some of the drugs should be consumed in order to stimulate ovaries for production of more ovules more than their normal level. A study showed that some of the fertility methods like IVF will increase the mental disorders in 2.4 percent of women. Among the different mental disorders, general anxiety disorders are the most prevalent disorders with 23.2 percent following with major depression with 17% of the cases. 3 The interpretation of the women's feeling with unsuccessful experience of infertility treatment is not studied enough. So in this study we are going to interpret the experiences of the women with unsuccessful infertility treatment. According to the previous investigations, it is clear that there are limited studies on this subject. The results of a study have showed that the psychological consultation would have an important role on the reduction of the women's stresses. 7 Other study on 150 women with SBRH. Volume 3, Issue 2, Nov 2019; 428-435 430 random sampling showed that the quality of life and the average depression among the infertile women is higher significantly in comparison with fertile women. 8 In order to investigate the results of several unsuccessful IVF on the quality of life and psychological situations, couples were categorized in two groups. 9 The first group is composed of 64 couples which are at least had unsuccessful experience of IVF treatment. The second group is composed of 56 couple with no unsuccessful experience of IVF treatment. The results of this study showed that the level of anxiety and depression between these two groups is significantly different from each other. The results of a qualitative study 10 showed that men and women had the same patterns of responses in regarding of fertility test and recovery of ovules. Other qualitative investigation with the subjects of identification of psychological feelings of infertile patients was performed extensively and the sampling in this study was done purposively. It could be concluded that infertility could influence on the whole life of an infertile couple. 11 The results of another query showed that infertile men in comparison with infertile women had a better quality of life. 12 According to this review on the previous studies, it could be concluded that most of the studies on infertility and methods of treatment are quantitative as studies with medical purposes. So in this case study, we are going to investigate a psychologically problems of infertile women in order to find new solutions to solve their psychological problems.

Methods
This is a qualitative study based on Grounded theory method. This approach is very important because it is a way in order to understand the feelings of the women. The population of this study is infertile female of Meybod City.
Cases of the study were 14 women which were selected with purposive sampling with the age of 23 to 50. Some parameters were selected to choose the participants including one experience of IVF, common life with their husband, having no godchild with consumption of mental drugs.
Data of this investigation were collected from semi-constructive conversations. Conversations were lasted from 40 minutes to 1 hour and 30 minutes based on the quality of the responses and desire of participants. For some cases more than one conversation was performed. In order to analyze data from the conversations we used from thematic analysis technique. For this purpose, data of conversations were type-written for the first step. For the next step every section of a text was coded and a specific concept was devoted to it. Similar concepts were converted to secondary themes and finally secondary themes were conjugated together in order to make final themes. In order to evaluate validation of the data we used from member control method. 13 For this purpose, the participants were asked to analyze the validity of final data after investigation and give their opinions about the results of the study. To have reliable data the list of the participants was provided and all of the data analysis process was type-written righted saved. To provide a suitable space for conversation we use from a woman writerto do their conversations. Before the performance of each conversation the purposes of investigations were explained for participants. Furthermore, time and the questions of the conversations were explained for their participants and their satisfaction before each performance was approved. In order to keep their private information of conversations all of the conversations and recorded voices are kept with secondary names and their real names of participants has been never used.
Following sentences are the questions of the conversations: Maine question: What are the familial and social experiences of women with several unsuccessful IVF? 4. How infertile women deal with outcomes of unsuccessful IVF?

Results
The participants of this study were 14 women with the age range from 23 to 50 years old. Their education degree was also different from elementary school to master degree education. In the table 1 is a summary of the characteristics of participants in this study.
After the first step of coding 348 primary code were collected and they categorized into five main groups including turning to spirituality, keeping the stability life, overcoming on mutual challenges, mental occupation and common acceptance.

Turning to spirituality
Many of the women with several unsuccessful experiences of IVF turn into a spirituality and religious issues as one of the best method for adaptation themselves. In this way they are trying to change their destiny and also to find peace and happiness. Some of the couples and also their relatives and families choose praying and invocation to find a way for solving their problem. "I, my family and the others were praying a lot for solving my problem". However, there were some infertile couples that they experience some unpleasant and undesirable feelings.
"I was feeling uncomfortable in all of the times my friends remind me that they had prayed a lot to solve my problem of infertility and I was not satisfied with their compassionate feelings".

Keeping the stability life
One of the main purposes of the infertile women in order to repeat their IVF was their strong desire to keep their, life and its attachments. Women with several unsuccessful experience of IVF were suffered a lot from the economical and mental pressures. They tolerate these pressures with the hope of keeping their life. We are going to feel our loneliness with having a child. "We don't have any problem in our relationship but sometimes we think that we are really alone and we are worry about our loneliness for our future". In some of the family couples or one of them understand instability in the family and they consider having a child as one of the most important ways to increase their sincerity and reduction off instability. "I have a lot of problems in my life and I think that having a child in our life decreases our problems and help us make our life more stable".

Overcoming of mutual challenges
There are many couples think about having a child as a way to increase close relationship and to reduce their dailiness of their life. Sometimes some husbands decide to accept the responsibilities of their life in order to reduce the pressure on his wife. So because of the love they ignore their natural right for having a child and following treatments. In fact, they accept childlessness because of the psychological and social pressures on their wife. Many of the couples who are involved in the treatment of infertility especially the women are not interested in their presence at the society, because most of the time they have to answer a lot of questions about there and infertility treatments. It should be noted that during the years after their marriage other's interference would be less significant and so being far from the people would be decreased by the time. "I was really sad and disappointed. I couldn't even participate in different ceremonies specially wedding ceremonies where I know that there would many little girls with beautiful clothes there. I suffer from watching little girls while I cannot have a child".
"We didn't have too much discussion for having a child. Once he decided to go for official application of child but I prevented him to do it".

Mental occupation
Sometimes for a couple or especially for a woman in the life with the problem of infertility, having a child is considered as a big deficiency in the life. This would be more important especially when the problem of infertility is because of the woman. Sometimes some couples get involved in SBRH. Volume 3, Issue 2, Nov 2019; 428-435 432 some extra ordinary programs in order to occupy their minds and reduce their thoughts about having a child. "Sometimes when I think about my problem off in fertility I feel absolute absurdity and I feel deficiency in myself. These feelings are annoyed me too much. In these situations, I decide to get involved myself in some extra ordinary programs such as artistic programs. But mental disturbance of having a child is always with me". Sometimes it could be seen that having a dream of a child is penetrating into their sleep and dreams. "Sometimes I dream that somebody is reproaching me for a having the problem of infertility. In these times I am getting nervous a lot".

Common acceptance
Sometimes for a couple, experience infertility problems, there would be instability in their life and their efforts to having a child would be as a natural trend in their life. In this condition there is a stability and peace in their life even without a child. This level of stability most of the time could be seen for women with sympathetic husbands. "My husband said that we have a peaceful life so it is not important to have a child or not. Maybe he is very busy. As a whole he doesn't care about having a child and he doesn't know it as a deficiency in our life. He believes that we could improve our quality of life and at the same time try for having a child. Sometimes a couple makes enough stability and variability in their life so that lack of a child dose not influences their relationship.
We are in love with each other even after 14 years of marriage, We believed out now if we are in the best in our relationships, We get used to have a life without a child and We try to adopt ourselves to this situation.

Discussion
Nowadays infertility is one of the biggest challenges in human life. 14 Every day the number of the couples which are affected by the problem of infertility is going to be increased. Infertility could be as one of the main reasons of divorce in many couples. 15,16 So in this investigation we are going to study the experiences of infertile women especially from their point of view. According to data collected from this study, women are worried about their husband's approaches for their infertility which makes them depressed and stressful. 17,18 Especially their several unsuccessful experiences in IVF treatment, increase the probability of their separation from their society. 19,20 For some cases infertile women suggest remarriage for their husbands, but most of the time this suggestion is rejected by their husbands, because they are interested in their life and they do not like to ignore their peace. For some of the couples with economical ability, it is not a challenge to afford expenses of several IVF and they would not have economic problems for future treatments. But for the other couples who are economically independent from their families, it would be hard to afford with economical experiences of IVFso they have to try hard in order to pay high expenses of IVF. Considering these data, high medical expenses of IVF and its related experiments are considered as one of the main reasons of stress for couples. 21,22 Spirituality has an important role in the life of a many couples. Especially the spirituality and praying play an important role for infertile womenin order to meet their dreams of having a child. 23 In some cases, there is dissatisfaction for infertile women because of unreasonable emphasize of the others on different invocations for a having a child. According to the claims of participants, getting involved in different activities and entertainments has no effect to forget infertility and childlessness. They are feeling deficiency in different situations in their life. But for the other infertile women getting involved in different activities was an approach to forget their infertility. 24 Finally, it should be noted that one of the main limitations of this study was non-collaborative couples because of their specific situation.

Conclusion
During the different conversations, we understood that there are different women with different point of views about infertility. These different ideas about the infertility are affected by different environmental parameters and communication factors, which are originated from their relationships with their husbands and the others. Some infertile women see infertility as a deficiency which makes them ashamed. For some women the negative point of infertility is losing the good opportunity of being as a mother. For some women who have a close relationship with their husbands, childlessness is like a lost piece of a family puzzle. So they try hard to create happiness for the family. Some other women think about infertility as one part of their destiny, so they accept it. For the other participant who suffers a lot from mental and physical pains and pressures of several IVF, infertility is a distressing and painful reality. Finally, it could be concluded that infertility has multi-effects on the couple's relationship.