Understanding the experiences of helplessness, fatigue and coping strategies among women seeking treatment for infertility – A qualitative study

Abstract

BACKGROUND:

Infertility impacts families and communities worldwide, affecting millions of people of reproductive age. The fertility rate in India is alarming. Fertility is valued in the majority of cultures, and having children is a fundamental motivation. The frustration and anger of an infertile woman affect her family, friends, and even her husband. This study aims to assess the factors that contribute to helplessness, fatigue, and coping strategies among women with infertility.

MATERIALS AND METHODS:

An in-depth interview was conducted among ten participants, to collect information about the challenges faced by women experiencing infertility. The participants were selected using a purposive sampling technique and they had at least 1 year of experience with infertility. A phenomenological study was utilized and themes and sub-themes were developed. Data was collected by using a list of probing open-ended questions and analyzed by colaizzi method.

RESULTS:

Women receiving infertility treatment over a long period of time disclosed that they are dealing with stressful situations in their lives. The experience left them feeling helpless in some stressful conditions. Due to a lack of both financial and emotional support from their family, when they are helpless, they are too worn out to continue their treatment. Some of these women are using different coping strategies to overcome their problems. We found seven common themes from this in-depth interview; 1) Lack of hope and support, 2) Spiritual resources, 3) Negative thoughts, 4) Social abstain, 5) Mental engagement, 6) Emotional concealment, and 7) Coping strategies.

CONCLUSION:

This study provides social, emotion and spiritual condition of infertile women in society. The majority of these women struggle with having negative thoughts due to a lack of support, concern, and involvement from their families. These results highlight the need to promote coping strategies, importance of financial and emotional support from the family members.

Introduction

Infertility is defined as the inability to conceive after one year of unprotected sexual activity in the absence of a known reproductive pathology. Primary and secondary infertility are possible. Primary infertility is a condition that refers to when a woman who has never conceived, whereas in secondary infertility a woman has conceived at least once.[1] Using the female's ability to conceive as a criterion to distinguish between primary and secondary infertility is problematic because it places the blame for a couple's infertility on the female partner.[2]

Infertility is a global reproductive health problem, affecting an estimated 48.5 million couples worldwide. Not only is infertility a reproductive health problem, for many people around the world infertility also constitutes an important aspect of their lives.[3] Infertility affects 8-12 percent of reproductive age couples worldwide, with 20-30% of infertility cases attributed to men.[4] Female factors account for nearly 46% of infertility, with polycystic ovarian syndrome being the primary cause. Secondary infertility is less common than primary infertility, with 57% affected by primary infertility and 42% by secondary infertility. In India, 8.8% of currently married women have suffered from infertility, with 6.7% and 2.1% suffering from primary and secondary infertility, respectively. Infertility is an alarming problem in India.[5]

For women, pregnancy and motherhood are developmental milestones that are highly emphasized by our culture. Even though family values have drastically changed in recent years, both men and women still place a high value on parenthood. Benyamini in his study has shown that from a social perspective, how women deal with infertility is related to how important they find parenthood and how actively they pursue fertility treatments.[6] In treating infertile couples, the assisted reproductive procedure can be stressful and problem for women's mental health.[7] A study reported that at least 50% of infertile women have said that being infertile has been the most distressing experience of their lives, and it has been found that their suffering is comparable to that of people who have other chronic illnesses like cancer.[8]

Many communities have a strong social stigma against infertility, which causes many social issues among infertile couples.[9] The stigma is related to a feeling of confidentiality and shame.[10] If infertility is perceived as a stigma, it may prevent an infertile person from receiving social support, lead to depression, anxiety, stress, and feelings of guilt, as well as cause relationship issues.[11] When trying for a long time and failing to conceive, it can be extremely disappointing and frustrating, especially when loved ones are not there to support you. Numerous studies have shown that infertile couples have a variety of needs for which they consider solutions such as counseling, couple-centered interventions, professional social and emotional services, and patient-centered strategies.[12] In a recent study, reported that there is no statistically significant relationship between social health and stress of infertility treatment.[13] Uncertainty and lack of control refer to the monthly expectation of treatment results, uncertainty about the future, and the sense of powerlessness they experience in their daily lives. Individual attitudes toward infertility typically depend on how society views gender roles and the value of fertility, and they develop within the context of that society's culture. Treatment stress may have had an impact on the participant's perceptions of infertility.[14] Concerns about childbearing are discussed in relation to family and social pressures. This affects the mental health status of the women receiving infertility treatment and prolonged duration of the treatment results in helplessness and fatigue.

Qualitative research can help create more effective interventional strategies by revealing more about the helpless, exhaustion, and coping mechanisms among infertile people. This study was conducted to investigate the experiences of infertile women regarding helplessness, exhaustion, and coping mechanisms, especially due to the dearth of qualitative research in this area. This study aimed to assess the helplessness, fatigue, and coping strategies among women undergoing treatment for infertility and to explore the various factors that contribute to the helplessness, fatigue, and coping strategies experienced by women with infertility.

Materials and Methods

Study design and setting

In this phenomenological study, colaizzi method was used for data analysis. This qualitative study was conducted with the voluntary participation of women who were diagnosed with infertility and monitored in the obstetrics and gynecology department at SRM Medical College Hospital and Research Centre, Potheri, India.

Study participants and sampling

The phenomenological method was used for the study consisting of a research sample of 10 women with infertility selected through a purposive sampling method. Data saturation was obtained after 8 participants were interviewed. To reconfirm data saturation, two additional interviews were conducted. Inclusion criteria for selecting participants having primary infertility were not having children and taking infertility treatment more than a year. This study also included participants who had secondary infertility and had been receiving treatment for more than two years.

Data collection tool and technique

The study was carried out intermittently between March 2022 to July 2022 at obstetrics and gynecology department at SRM Medical College Hospital and Research Centre, Potheri, India. The in-depth interviews were conducted at the interviewee's convenience. Interview was conducted by the first author in a separate room in the department of obstetrics and gynecology. The interviews lasted between 50 and 90 minutes and covered past and present desire for motherhood, experiences of diagnosis and treatment, consequences of infertility, coping responses, and the impacts of COVID-19 lockdown. Interviews were fully recorded and field notes were also taken during the interview. The interview began with the question “what did you know about infertility?” Following that, questions were asked about experiences faced by the infertility treatment and needs from the society. Then probing questions were asked related to support from the peers, family, and friends. Since interview dynamics and participant expectations can influence data collection, care was taken to establish an empathic rapport in which interviewees felt at ease discussing their experiences. The interviewer assured participants of their anonymity and clarified that she was more interested in their experiences than “right” or “wrong” responses. Researchers were ultimately motivated by a desire to enhance the psychosocial well-being of infertile women, but we conducted the research focusing on participant accounts.

Data analysis

Using the colazzi method, data was coded and related themes were developed. Themes were developed by both inductive and deductive method. These themes included the reasons for experiencing infertility, current emotional states, the reactions of families to infertility, the general opinions of people about women with infertility, the effects of meeting with people who were aware of their stigma, and impact of COVID-19 lockdown on getting treatment. These themes were assessed and compiled in the findings and discussion sections.

All the interviews were performed by the first author. The recorded interview has been listened and transcribed into verbatim after each interview. Based on the transcript, each interview was read line by line and re-examined by another author. Data collection was continued until getting the repeated data emerges. After 10 interviews, data saturation was achieved. The narrative dataset was extracted, organized, and analyzed with the help of the colaizzi method.

Colaizzi's method of phenomenological data analysis demonstrated an active approach to describing the real-life experiences of women receiving infertility treatment and the coping mechanisms they employed. Then, significant statements were found, and these were transformed into formulated meanings. There were developed themes and subthemes. Lincoln and Guba (1985) base their evaluation of trustworthiness on four broad standards. These include dependability, confirmability, transferability, and credibility.[15] Three participants looked over codes, subthemes, and themes in order to achieve these criteria. They confirmed to the accuracy of the interpretation of the themes. The three other infertile women who did not participate in the interview looked over the themes and subthemes. The two persons who were familiar with the qualitative data also looked over codes and subcategories. Finally, MAXQDA10 trial version is used for data analysis. Themes and subthemes were reviewed by all the authors.

Ethical considerations

Before data collection ethical clearance was obtained by the researcher from the institutional ethics committee, SRM Medical college Hospital and Research Centre, Potheri, India (ethical clearance number: 3067/IEC/2022). The participants will be given an introduction about the principal investigator (PI) and the project. The participants will be elaborated about the study and the benefits of the study. Informed consent and the details of it will be explained to the participants. Informed consent form was obtained from each participant before the interview.

Results

A total of 10 infertile women, between the ages of 23 to 34 years old with a history of primary and secondary infertility were included in this study. Three of them were having secondary infertility and seven of them were having primary infertility. When undergoing fertility treatment, couples deal with difficult decisions regarding treatment plans, side effects, ongoing process of treatment, and the diagnosis of infertility. Among the study participants, only one person was aware about pre-marital counseling. Most of them is not willing to attend counseling. The study participants took time to initiate the treatment for minimum of 6 months to 4 years. The participants were having infertility for a period of 1 year to 12 years. The remaining demographic characteristics are explained in Table 1. The study participants mostly describe about their husband, family, friends, and the support they get from them for the treatment which is presented as word cloud [Figure 1].

Table 1.

Demographic details of the study participants

P.no	Age	Type of infertility	Type of marriage	Religion	Family income in rupees	Family income in dollars	Duration to start treatment
P1	28	Primary	Consanguineous	Hindu	50000	611.42	2 years
P2	34	Primary	Non-Consanguineous	Hindu	8000	97.83	4 years
P3	28	Secondary	Non-Consanguineous	Hindu	50000	611.42	2.5 years
P4	27	Primary	Consanguineous	Muslim	30000	366.85	2 years
P5	23	Primary	Non-Consanguineous	Hindu	15000	183.43	6 months
P6	24	Primary	Non-Consanguineous	Hindu	10000	122.28	6 months
P7	27	Primary	Non-Consanguineous	Hindu	19000	232.34	1 year
P8	30	Secondary	Non-Consanguineous	Hindu	15000	183.43	1 year
P9	32	Secondary	Consanguineous	Hindu	40000	489.14	6 months
P10	34	Primary	Non-Consanguineous	Christian	15000	183.43	4 years

Figure 1.

Word cloud

According to Seligman's learned helplessness theory, they have no control over what occurs to them, they start to feel, think, and act helplessly. An acquired conduct has been influenced by situations in which the subject either actually lacks control over his/her circumstances or merely believes that he/she does not.[16] Based on these research findings were coded into 7 themes and 33 sub-themes [Table 2]. The coded themes that are generated to helplessness were lack of hope, spiritual resources, social abstain, negative thoughts, and lacking support and the themes generated for fatigue are mental engagement and Emotional concealment. The theme generated for problem solving skills was coping strategies.

Table 2.

Themes and sub-themes for helplessness and fatigue

Themes	Sub-themes
Lack of hope and support	Frustration, conflicts in family, giving up, lack of confidence, financial issues, Lack of support.
Spiritual resources	Praying to God, blaming god, cultural belief
Negative thoughts	Delay in treatment, changing hospital, self-hatred, suicidal thoughts
Social abstain	Stigma, reputation in society, neglecting social involvement
Mental engagement	Constant worrying, feeling of isolation, cry, exhaustion, treatment failure, stressful experiences
Emotional concealment	Maintaining secret, anger, guilt, worry, sorrow, neglecting difficult situations.
Coping strategies	Passivity, self-management, traditional medicine, factors giving hope, adoption.

Lack of hope and support

Infertile women who experience lack of hope as a result of unsuccessful treatment may feel helpless because it is implied that they will not benefit from treatment or be able to lead fulfilling lives.[17] Based on Seligman's theory of learned helplessness, the study participants show similar symptoms like frustration, giving up, lack of confidence, passivity, and hopelessness.

Frustration

When the participants were asked about their frequency of pregnancy test during treatment process, they felt sad, frustrated, and lost hope when their pregnancy test results were predicted. For some of the participants, the frequent use of hormonal treatments, non-medical interventions like IUI and IVF, and recurrent failures were frustrating.

“My relatives ask usually, “its been 3 years of marital life and still you didn’t conceive.” My body is like that, what I can do for that. Sometimes it hurts a lot, we would manage by telling about my treatment process. But once we reached home we were under great sadness and frustration.” (P6)

Conflicts in family

As the marital relationship is viewed as the most significant source of support in the perspective of infertility treatment, this can be problematic among couples. The threat of divorce to leave their home is made to women.[18] Men are often found to threaten their wives by giving them a timeline. They are having conflicts due to childlessness. One of the participants expressed his feelings saying,

“I will give you time only for this one month. If you didn’t conceive in this one month, you should go to your mother's house. He said that, “I will send you divorce notice; you just sign and leave. I will remarry someone.” I cried a lot and also I felt that it's better to die”. (P6)

Giving up

Participants, who took treatment at the starting stage for more than two years, discontinued the treatment and many decided to give up when treatment gets failed repeatedly.

“Due to financial issues, we stopped taking treatment. If my treatment gets failure, I will drop out the plan to continue treatment”. (P10)

Lack of confidence

Without hope, a goal cannot be recognized, and hope also gives people the illusion that even the worst-case scenario won’t affect them.[19] One of the essential psychological requirements is hope. In other words, hope creates internal feelings of confidence and positivity toward a specific thing or event. In our study, the participants lost hope in many situations during the treatment process.

“I got pain 6 days prior to my menstruation, I guess that time my result would not be positive. So I don’t have hope for doing pregnancy test.” (P1)

Financial issues

In our study, most of the participants lacked financial support for their treatment and treatment process. Those who were under treatment for longer durations were denied financial support from their spouse and family members. For example,

P6 stated, “Sometimes, he (husband) won’t give me money for treatment. When I got my menstruation, if I ask money to go for a hospital and to buy medicine. He says, “I can’t afford it”. You always get your menstruation regularly for that why I have to afford money. Get your treatment amount from your mother”.

Lack of support

The majority of participants, however, felt some form of sadness as a result of their husbands blaming them for their infertility, their families expressed concerns, their community's negative reactions, or neighbor's reaction [Figure 2]. For example,

Figure 2.

Treatment support

“my mother-in-law use offensive words that,” it's been 3 years of marital life still you don’t have a baby”. My sister-in-law would speak behind me in a certain way. They used to say, “You are not worth for anything.” (P6)

Spiritual resources

Praying to God

In some situations, the participants lose their controls and emotions due to childlessness. When they are losing hope, spiritual beliefs play an important role in controlling their emotions. The participants believed that praying to God helped them. One of the participants expressed his feelings saying,

“I have lot of belief in God. I always pray to God. I believe in God one day he blesses us with a baby.” (P9)

Blaming God

When the participants get disappointed, they are losing hope in God and they stop doing all the rituals. Those who are frustrated develop negative ideas about the God. Due to increased belief in God, when facing failures, the study participants blame God for not having baby. They get depressed and frustrated when expectations are not met. One of the participants expressed his feelings for blaming god,

“I had a lot of hate. I will fast for everything to get a baby. Even when I fast, god didn’t give me anything. Some persons they don’t even pray to god they are all getting baby but why I didn’t get a baby. (P6)

Cultural belief

Religion significantly affects daily life in India. Numerous religious texts and ancient stories serve as the basis for a variety of reproduction-related values and beliefs. God, who is regarded as the creator, is the only one that can give life. A large number of participants said they have complete faith in God and accept infertility as God's will. Many believed that having a baby was a blessing from god and many strongly believe the horoscopes and following many rituals will help them get pregnant. For example, one participant stated

“I worried a lot for a year. After that I went to many temples and seen horoscope. They told me that, I will get a baby. It gives me little confidence to continue my treatment.” (P9)

Negative thoughts

Delay in treatment

Treatment delays can occur when sudden outbreak or any natural disaster occurs. In recent days, the onset of COVID-19 affected major health-related issues and it became a challenge to seek proper medical care at the right time. During lock down, most of the people took treatment in home. Those who were taking infertility treatment were not allowed to continue treatment during the outbreak. Due to this outbreak, treatment process was delayed and often stopped.

P3 stated, “I felt worried at that time, that I can’t able to continue my treatment due to Covid-19. My treatment process gets delayed; it's been 3 years we are trying to get pregnant”.

Another reason for delayed treatment for the women taking treatment for secondary infertility was the long gap after having their first baby. Many women reported that, they didn’t have time to plan for their second pregnancy when rising their first baby.

“There is no one to look our baby. so, we waited for two years to grow our first baby. After trying for a year for second baby, we didn’t conceive” (P9)

Changing hospital

When the treatment failed, most of the people search for another hospital or clinic. Our study participants show similar attitude for changing hospitals when their first attempt fails.

“Already we went treatment to one hospital. It is not cured so we changed hospital for taking treatment.” (P5)

Increased cost was the other major reason for changing hospital. One of the participants expressed,

“In two places, we took treatment. Due to high fee structure, we changed hospital.” (P6)

Self-hatred

When they are change hospitals, they lose confidence and later hate themselves for not continuing treatment. When left helpless, they had the strong feeling of self-blame for all the things that happened in their life. One of the participants expressed his feelings,

“When my husband scolds me, “I hate myself more”. I also think that why God has created such a disease for me”. (P6)

Suicidal thoughts

When they were alone, the participants had more thoughts that are negative like suicidal ideations. For example, one of the women expressed her thoughts that

“I always think, why I am living in this world? I should run somewhere to get relief from my problems”. (P6)

Another participant expressed,

“Sometime I feel like I should not be alive and am not worth to live my life. There is no use to live in this world.” (P10)

Social abstain

Stigma

For women, pregnancy and motherhood are developmental milestones that are highly emphasized by many cultures. When attempts fail to have a child, they are ignored by the relatives and neighbors. Some of the participant's feelings revealed their anguish and sorrow.

One participant expressed,

“If any functions like baby shower and baby birthday happen in their house. They ignore us by not inviting us to that function and not informing us about the functions at all.” (P7)

Reputation in society

Infertile women are viewed differently than other women because they are unable to carry out the predetermined role of the female as recognized by society. For example,

“It was very difficult. Society looks us having children is the main thing. They will consider us as women only if we are having children. There are more chance to take mental pressure and went to depression. We are in that situation only.” (P3)

Neglecting social involvement

Most of the study participants were upset and neglecting to participate in social functions. Some of the participants voluntarily avoiding to participate in functions like baby shower function and children's first birthday celebration. Another participant expresses his feelings in a way that they were ignored for attending functions.

For example, one of the participants expressed

“I was feeling very tensed, if I attend any function the people will start hurting me, so I can’t go for any good and bad things that happen around me, so I ended up staying at home for 1 year without attending any functions. Very rarely I will attend the marriage function but I won’t attend any baby shower functions. If I went there, they would say hurtful words.” (P2)

Mental engagement

Constant worrying

Pre-occupied thoughts would be the main reason for continuous worry. Most of the infertile couples had plans for baby and they are thinking more about their future. Fatigue was more common among the persons receiving infertility treatment. According to participant experiences, fatigue experienced by constant worrying, feeling of isolation, exhaustion due to repeated failures in treatment and stressful experiences due to infertility. In addition, the study participants had fear to ask help from their spouse and they are always pre-occupied about their spouse reactions towards them. For example,

“Sometimes my husband uses to say unkind words. If I asked him to recharge my phone, he said, “you are not useful for anything, then why I should recharge”. (P6)

Feeling of isolation

Another participant shared his feelings that they are mentally engaged by thinking about their issues and they are finding solutions for their problem. Sometimes they felt alone even had so many relatives, friends, and neighbors. For example,

“I experienced many times that I am alone even when many people available around me.” (P7)

Cry

Long stretches of crying and isolation were among the depressive symptoms they described. This is further supported by the taboo surrounding infertility, which makes it challenging for women to express their worries and stress. One of the participants expressed her feelings,

“when my relatives ask about my pregnancy in functions, “I used to go rest room and cry a lot, after washing my face I will go home silently.” (P3)

Exhaustion

Infertility can be mentally and physically difficult, which can result in depression and loneliness. Patients who are having trouble getting pregnant usually describe feelings of depression, anxious, lonely, and completely out of control. The study participants expressed feeling of isolation and losing their control in some difficult situations. Also, the participants who had hidden their feelings were engaged mentally and not active in doing their day-to-day activities. This affected their daily routine life and personal relationship with their family, relatives and neighbors. When they felt like they lost their control, most of the study participants preferred to cry at bedtime. For example, one woman expressed his feelings in choked voice

“For the past 3 years, I had disturbed sleep by thinking about my problem. It's been five years, and now it gave exhaustion. We are going to the hospital and taking treatment, let it be when it is happens.” (P7)

Another participant expressed,

P-10 stated, “the frustration gets increased and also having increased stress. Sometimes mentally get exhausted without knowing what to do next, silently I will go to bed. I don’t feel like doing any work, I will be under a great distress”.

Treatment failure

When they are alone, their thoughts are about their future plans with their pregnancy, child and financial management. For example,

“when treatnment gets failed repeatedly we have little fear that if we spent money only for treatment when the baby comes, we can’t do anything for the baby”. (P7)

Stressful experiences

According to our study findings, many women experienced stressful events in their life due to infertility treatment and they have felt disappointed to take any further treatment. Following repeated infertility treatment failures, they were experiencing extreme emotional distress. For example,

P6- It will be very difficult. “If I saw persons with a baby, I wish the same thing that needs to be happen for me.”

Emotional concealment

Maintaining secret

Secrets cause shameful feelings. They create distance between family and friends and foster miscommunication. People may assume infertile couples who are determined to keep their condition a secret don’t want children, are selfish, or are naive to believe they can delay conceiving children forever. According to participant's experience, many of them decide to maintain this as a secret and not reveal their truth to anyone. For example,

P1- “I will not share about my treatment process; even I won’t discuss and share with my family members”.

Anger

Even the participant's experiences personal emotions such as anger, guilt, sorrow, and worry due to childlessness. For example,

P-10 stated,” I think in my mind, “If I got baby, am the person going to bring up my child. What's your problem, why you are involving in this?” Don’t interfere in another's life, see your own problems”. We can’t able to tell this directly, we just silently move on by smiling because no other options.”

Guilt

The guilt feelings expressed in our study participants who receive supportive care from their family members, particularly from their husbands, feel guilty for not being able to designate their partner the father of a child. For example,

P3 “My husband felt worried, cried and said “what we did in the past is wrong”. If we do not done abortion in the past, now we won’t face these issues and we would have baby with us now.”

Worry

Additionally, participants were occasionally upset to hear about neighbor's pregnancy or delivery, to hear about her husband and children. Similar results were found in our study findings, as one of the women expressed his feelings in way that,

“In my family everyone having baby. I felt worried when I realized that I don’t have baby”.(P1)

Sorrow

Many participants have developed sadness and depressed after experiencing feelings of anger and guilt. In our study, the participants hiding their emotions when they are hurt emotionally. For example,

“Once upon a time, my periods were delayed. Therefore, we both eagerly tested for pregnancy. The next day itself, I got my periods. We both underwent deep sorrow. I felt very difficult to overcome failures.” (P7)

Neglecting difficult situations

When participants were upset, they neglected to participate in social functions. Sometimes they feel alone and they were avoided for doing rituals at the functions. For example,

“In every function, I can’t able to stand in front while doing all the rituals. If I went to functions also, I will go and sit on the side. If someone says you are not having a baby so you don’t do anything, it hurt us a lot” (P10)

Coping strategies

Women often found ways to cope through various ways like self-management, traditional medicine, and special diets to become pregnant. The participants were following these methods to overcome the issues faced by them mentally.

Passivity

Most of the couple faces social issues it affects them emotionally. Many of them were ready to accept their problems related to childlessness. In our study, one of the women thinks that their effort for getting treatment will give better results in future. Therefore, the study participants continue treatment without giving up. They had a strong desire that they will never give up on taking treatment after getting failure also.

P6- I will console by myself that, “If I didn’t get pregnant this time, next time definitely I will be pregnant”.

Self-management

When they are seeking information about childlessness through social media, they get some idea about the treatment process and ready to continue their treatment. One of the participants expressed his feelings in his way that,

“if anyone insult us, for that 5 min it will hurts. If I cried, my feelings would be better and I feel relaxed. Had strong opinion that I will get baby one day, at that time we would show our attitude” (P-3).

Some participants felt relaxed when they are attending any diversional therapies like attending yoga class and listening devotional songs. One of the participants said,

P6- By doing household works I will divert my mind”

Traditional medicine

Traditional medicine, which has been practiced for thousands of years, claims that it can treat some types of infertility by changing a person's diet and lifestyle. However, many participants following traditional medicines which were followed in their culture for the treatment of infertility. For each culture, administration of traditional medicine varies based on their geographical location and culture. One of the participants shared his experience,

“usually, old age people say to take sesame seeds. I took sesame seeds in the past. After marriage they gave me chinaberry powder. They grind it and mix with water. I took this water in an empty stomach at early morning. It's a myth in village side that it cleans and send the germs outside.” (P6)

Factors giving hope

Most of the study participants get hope from doctor's advice, support from spouse, family, relatives, and neighbors. Sometimes their spouse comes with them for treatment because it is too long to come from home to hospital. Doctors would say don’t give up, have hope and try one more time. With that hope only many came for treatment. One participant expressed,

“Nowadays advanced treatments are available. So, I thought,” let's try for some more days”. Based on the doctor's advice and treatment process have to take the next decision.” (P7)

Adoption

For the couples facing childlessness issues, adoption would be the better way to enjoy their parenthood. However, many participants are not willing to adopt. It is the couples and even the family members, relatives, and colleagues who are not willing to accept adoption as an option for themselves [Figure 3]. One of the participants stated,

Figure 3.

Adoption (willingness of participant's relatives)

P3- “if we ready to adopt a child, it will affect the children future because the surrounding people and society will say anything about adopted child. If we took the adopted children to my relative's house, they will say something hurtfully. We don’t want to insult the child by adopting and spoiling their future. So, we don’t have adoption plans”.

Discussion

This study mainly focuses on the participant's lived experience of infertility treatment. In that, the study participants experience feelings of failure and helplessness followed by lack of hope. Similarly, results reported in a study conducted by Hasanpoor et al. that the persons receiving treatment, people reported struggling with self-control, having low self-esteem, and experiencing feelings of failure and helplessness.[11] The feeling of complete helplessness during the treatment-seeking process was highlighted by several women as one of the biggest difficulties associated with infertility. Because they had no control over how any given cycle would turn out, women expressed a considerable measure of frustration.[20] The infertile women in this study, as mentioned by Greil et al., have also struggled with mental health issues, such as anxiety, grief, stress, and depression.[21] A number of issues, including low self-esteem, anxiety, depression, guilt, and grief, were mentioned in earlier quantitative study.[22] Compared to men, women are more likely to feel helpless. Women report being less accepting of their infertility issues.[23] Our study results show that most of the women's lack hope, and they felt helpless during the treatment process and they are seeking support from their family and relatives. Helplessness was linked to a greater negative impact of procedure on mental health issues.[24] More than half of respondents (60.4%; n = 1174) believed that their mental health had been impacted by the fertility problems.[25] Our study findings reported that mental health issues like depression, anger, guilt, worry, and sorrow. It is obvious that infertility causes psychological issues because infertility patients frequently report high levels of anxiety and depression. One in four people struggle with this widespread issue.[26]

It was discovered that infertile women occasionally felt hopeless and suffered from mild stigma.[27] In our study, the findings were similar that most of the study participants facing social stigma and lacking social support. In a study by Lawson et al., reported that age, the duration of infertility, and the use of social support were all associated with distress (P 0.001).[28] Our study findings shows that the study participants neglecting to participate in social functions like marriage function, baby-shower function, naming ceremony function, and ear-piercing ceremony. When they are neglected to participate in social functions, they showed negative thoughts, feelings of isolation and suicidal thoughts. In a study reported that 9.4% of people were at risk of committing suicide. Women who attempted suicide had higher depression levels and were more likely to be childless or to have fewer children.[29]

The events that occurred during the treatment process such as understanding that a pregnancy test was negative; many of the participants get frustrated, especially after spending so much money.[11] Infertile couples also frequently hide their feelings, thoughts, and beliefs because infertility is still regarded as a private issue. As a result, infertile couples might experience social pressure. In a study reported by Kim et al., reported that women hide their negative feelings due to the stigma associated with infertility because of the diagnosis itself.[30] Cousineau TM et al., reported that 62% of respondents tried to cover up from family and friends, 53% of respondents hide their feelings from their partner, and 65% of respondents feel angry and frustrated when others have easy pregnancies.[31] These results were similar with our study that the participants get frustrated and worry when they hear about family or neighbor's pregnancy.

The study results reveal the personal experiences of women facing issues due to infertility treatment. By using in-depth analysis, the study findings were presented and it helps to define better about the helplessness, fatigue, negative thoughts which were experienced by the women. This means that it can significantly advance both the knowledge regarding infertility problems and the scientific application to overcome these problems. The most valuable information that needs to be communicated to infertile couples at the right time was helpful when it becomes biologically too late to obtain childbearing and the accessibility of other facilities at a later age.

Limitation and recommendation

The current study also emphasizes coping strategies, support from family of the women who are experiencing infertility. Future research should, however, look at the couple's and their family member's helplessness and fatigue as well. The sample of this study is not thought to be representative of all infertile women in India because generalization is not a goal of qualitative studies. The private hospital's performance is reflected in the results. Consequently, it might not be representative of other private or governmental settings. It is advised to carry out more in-depth research in this area.

Conclusion

This study provides a deeper understanding of the personal, social, emotional, and spiritual conditions of women undergoing prolonged infertility treatment. The findings also indicated that peer pressure from neighbors is one of the primary causes of psychological distress. They are looking for financial and emotional support from their spouse and family. Negative thoughts, such as a sense of isolation and suicidal notions, arise when a person lacks support. Due to stigma, they felt ashamed for attending social functions. The stigma is associated with a sense of guilt and secrecy. Prior to beginning any medical treatment for infertility, patients should undergo counseling. The majority of study participants were unaware of premarital counseling. They are unwilling to attend counseling regarding the infertility treatment process and mental health therapies. It is advantageous to incorporate psychological therapies into the everyday procedures of an ART clinic. Supportive interventions are used to assist family members of infertile couples in altering their perceptions of the problem and preserving their positive relationships with infertile couples. It is anticipated that their encouragement will convince the couples to adhere to the treatment protocol.

Financial support and sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors

Conflicts of interest

There are no conflicts of interest.