Women living with infertility in Iran: A qualitative content analysis of perception of dignity

Abstract

Background:

Globally, infertility is known as a major problem which can ruin a couple’s relationship. In recent years, many studies have addressed the causes of infertility, the outcomes of treatments for infertility, and the effects of infertility on couples’ mental health; however, the concept of dignity of women living with infertility has never been examined in depth.

Objective:

This study aimed to explore the dignity of women living with infertility in Iran.

Design:

This qualitative research was conducted via conventional content analysis approach.

Methods:

This qualitative study was conducted in Iran from February to December 2022. In this research, the data were collected through face-to-face semi-structured in-depth interviews with 23 women living with infertility selected via purposive sampling. The interviews were continued until reaching the data saturation point. Data analysis was performed simultaneously with data collection. The interviews were recorded, transcribed, and analyzed through Graneheim and Lundman style content analysis, with data management done using the MAXQDA software. To achieve the accuracy and validity of the study, the four-dimension criteria by Lincoln and Guba, namely credibility, dependability, conformability, and transformability, were considered and used.

Results:

Analysis of the qualitative data yielded three themes and eight subthemes. The three main themes were (1) overcoming identity crises (overcoming dysthymia, coping with unaccomplished motherhood), (2) respect for personal identity (respect for confidentiality; respect for beliefs, values, and attitudes; avoidance of stigma and pity), and (3) compassion-focused therapy (sympathizing, mental and spiritual support, and enhancement of life skills).

Conclusion:

Dignity of women living with infertility encompasses overcoming identity crises, respect for personal identity, and compassion therapy. The policymakers and administrators in the healthcare system can use the findings of this study to create a proper clinical environment toward preserving the dignity of women living with infertility.

Introduction

Infertility is a serious health problem worldwide, affecting almost 8%–17% of couples globally. ¹ According to the World Health Organization (WHO), 186 million ever-married women in reproductive age in developing countries are affected by infertility. ² Based on a meta-analysis of population surveys published since 2023, the prevalence of infertility in Iran was estimated to range within 11.3%–25.3%. Also, the average costs of infertility treatment in Iran range between US$1500 and US$2500. ³

Although over the past decades many efforts have been made to treat infertility, these treatments are often very costly. ⁴ In addition, occasionally, a treatment procedure needs to be repeated several times before the desired outcome is accomplished. ⁵ In many cases, fertility treatments end in failure, which can turn into a devastating emotional experience for couples, subjecting them to severe psychological tension. ⁶ In societies where there is a high rate of fertility and fertility is very important for their families and couples for cultural and social reasons, the psychological tension experienced by couples living with infertility is even more severe and can lead to a mental crisis. ⁷

However, even though both couples experience tension, studies show that the psychological consequences of infertility influence females more than males.^1,8

Couples living with infertility often experience a roller coaster of emotions. “A roller coaster of emotions,” can stress the coping mechanisms within the couple, causing psychological and physical withdrawal from each other, communication breakdowns, and sexual dissatisfaction. ⁹ Women are more likely to endure the risk of negative effects of infertility than men, such as feelings of shame, self-blame, grief, sadness, lack of femininity, emotional exhaustion, social isolation, low self-esteem, diminished sexual satisfaction, and a lower quality of life. ¹⁰ Kiani et al.^11,12 have estimated a 44.32% prevalence of depression and 54.24% prevalence of anxiety in women living with infertility in low- and middle-income countries and 28.03% prevalence for depression and 25.05% for anxiety in high-income countries.

In recent years, many studies have explored the causes of infertility, the outcomes of treatments for infertility, and the effects of couples living with infertility mental health.^13,14 Also, several qualitative studies have investigated these women’s life experiences and the psychosocial consequences of infertility.^{14 –16} Yet, the concept of women’s dignity and the consequences of infertility in different societies have not been studied so far, especially in East Asian societies, where having a child is seen as one of the women’s primary roles.

Dignity is defined as an individual’s inherent value and worth which is strongly linked to respect, recognition, self-worth, and the possibility to make choices. ¹⁷ It is influenced by individual characteristics and depends on social, cultural, ethnic, religious, and political factors. ¹⁸ Thus, it is crucial to examine the concept of dignity and the factors related to it in women for preserving the dignity of this group in the Islamic culture of Iran.

According to the abstract and complex nature of the concept of dignity, a qualitative approach can be very helpful in investigating these women’s dignity. The aim of this qualitative research is to explore and understand humans’ profound experiences. Every individual’s perception of the truth is formed by his or her experiences; thus, a researcher can establish the meaning of a phenomenon from his or her perspective only by entering an individual’s world of experiences. ¹⁹ This study was conducted to explore the dignity of women living with infertility in Iran.

Methods

This qualitative study aimed to explore the dignity of women living with infertility in Iran based on conventional content analysis. This method was used to collect rich, novel data unconstrained by preconceived categories. Qualitative studies focus on the individuals’ perception of reality, where the meaning of the phenomenon under study emerges from an investigation of the components of the whole. ²⁰ The reporting of the study was based on the consolidated criteria for reporting qualitative research (COREQ) checklist. ²¹

Participants

The participants consisted of 23 women living with infertility who had a medical record at one of the state fertility centers affiliated to Fasa university of medical sciences (FUMS) in Fars Province in the south of Iran. The study was conducted from February to December 2022. The inclusion criteria were being willing to participate in the study, being able to speak and understand Persian, not being affected by a severe mental or physical disorder, having received treatment at a fertility center for at least 5 years with no success, and being able to provide rich information about the subject of the study. The potential participants were selected via purposive sampling and invited to participate in the study. Those who were not willing to continue participation for any reason were excluded.

Overall, 35 women living with infertility were invited to participate in the study, but 12 participants refused due to busy schedule, infection with COVID-19, and spending time with their families. Thus, the participants consisted of 23 women living with infertility who were selected via purposive sampling. After consulting the manager of infertility clinic, the researchers selected one of the personnel who could interact better and provide rich information for the initial interview. Then, the first participant was asked to name a colleague who had rich knowledge and experience of the subject under study. Accordingly, based on the information provided by the participants chosen earlier, more participants who had a good understanding of the subject of the study were selected.

Data collection

Data were collected using individual interviews. Accordingly, 23 semi-structured interviews were conducted face-to-face in a private environment with prior arrangement with the participants. The corresponding author (M.B.), who is an Associate Professor of Nursing leading numerous qualitative studies, conducted all the interviews in the conference room of the fertility centers affiliated with FUMS in Fars Province in the south of Iran.

Each individual interview began with a few general questions, including: Can you describe a typical day in your life? “What is your definition of dignity?,” “In your opinion, which factors affect women living with infertility dignity?,” and “In what situations has your dignity been undermined?” Next, based on the participant’s responses, additional questions were raised. The researchers made an attempt to conduct the interviews in line with the main objectives of the study. If necessary, follow-up questions were asked to further clarify the data: “Can you explain further?,” “What do you mean by that?,” or “Can you give an example?” With the prior permission of the participants, the interviews were recorded. Each interview lasted between 55 and 75 min. Immediately after completion, the first author listened to each interview several times, trying to gain a deep insight into the subject. Next, the interview was transcribed. The collected data were analyzed after each interview, and the next interview was planned accordingly. The interviews continued until the data were saturated, that is, no new categories could be extracted, and the categories were saturated in terms of characteristics and dimensions. ²² In this study, we reached data saturation after 21 interviews; however, to confirm that the data were saturated, the researchers conducted two more interviews. Supplementary file 1: (Interview Guide and English language Interview)

Data analysis

Once the data were collected, they were analyzed according to Graneheim and Lundman’s method for qualitative content analysis, ²³ which is a method for analyzing written, spoken, or visual messages. In this type of analysis, inferences are made from raw data, which are subsequently summarized and placed into categories and themes. ²⁴ Qualitative content analysis is a research method which allows for mental interpretation of the text data through systematic categorization, coding, and theme development or establishment of known patterns. ²⁵

Initially, for immersion in the data and acquisition of a grasp of the whole, the researchers read the transcript of each interview several times. Next, the words, sentences, and paragraphs which were significant regarding dignity of women living with infertility were chosen as meaning units. Similar meaning units were labeled, and the transcripts were coded. Then, the codes were examined in terms of their similarities and differences; similar code was merged, and the codes were compared to the transcripts. Based on their similarities, the data were classified, where categories emerged. To confirm the consistency of the codes, the researchers re-examined the categories and compared them to the data again. The themes were identified after deep and accurate contemplation of the categories.

In summary, in this study, the following five steps were taken as recommended by Graneheim and Lundman (2004): (1) transcribing each interview in full immediately after its completion, (2) reading the entire transcript to obtain a general understanding of it, (3) determining the meaning units and initial codes, (4) classifying similar initial codes into broader categories, and (5) selecting an appropriate heading which covers the categories. ²³

Accordingly, immediately after each interview, the first author (F.M.) transcribed the interview and marked the significant paragraphs. The words, sentences, and paragraphs which were significant about the women’s dignity were chosen as meaning units. Each meaning unit was assigned a code. In the next stage, the second author (S.J.) inspected the transcripts and verified the identical meanings and codes. Next, similar codes were merged to form categories. To confirm the reliability of the codes, the researchers inspected the categories and compared them to the initial data. Eventually, after several meetings attended by all the researchers, the research team examined and compared the topics and extracted the themes. The collected data were analyzed in MAXQDA v. 2007 (Table 1 reports the examples of the process of data analysis).

Table 1.

An example of coding and development of subthemes and themes.

Meaning units	Coding	Subtheme	Theme
Sadly, the treatment teams and doctors don’t respect the confidentiality of their patient’s records and share the patient’s medical or personal information with others without getting permission from the patients. (Participant 11)	Confidentiality of their patient’s records. Share the patient’s medical or personal information. Permission from the patients.	Respect for confidentiality	Respect for personal identity
In my opinion, spiritual and mental support is the most essential part of compassion-focused therapy for women who are suffering from problems related to their infertility, especially in the long run. Unfortunately, no one considers the mental and spiritual needs of women living with infertility. People think that this type of support is proper only for the terminally ill, like those who have cancer. The feelings of frustration, severe mental stress, depression, and worthlessness are sometimes so unbearable, and I don’t think other patients experience them. (Participant 20)	Mental and spiritual needs of women living with infertility. Feelings of frustration, Severe mental stress, Depression	Mental and spiritual support	Compassion-focused therapy

Rigor (Trustworthiness)

Lincoln and Guba’s criteria (credibility, dependability, confirmability, and transferability), used to ensure the trustworthiness of the data, were used to check the trustworthiness of the results. ²⁶ Accordingly, at the beginning of the study, the researchers put aside all their prior knowledge and personal beliefs about dignity in nursing, so that their personal opinions would not prevent them from providing an accurate description of the phenomenon under study. To enhance the credibility and accuracy of the data, the researchers employed prolonged engagement (10 months) member checking and peer review. Thus, the extracted concepts and themes were presented to five of the participants and four peers, who declared that the findings were consistent with their perceptions and interpretations. Furthermore, at the onset of the study, by limiting the literature review, the researchers tried to reduce the possibility of bias in collecting and analyzing the data and assigning codes to the participants’ statements, thereby boosting the reliability of the data. To ensure the dependability of the data, the research team was regularly updated on the progress of the study and several external advisors were given access to the findings of the study, so that they could examine the process of data analysis. Finally, the confirmability and transferability of the data were ensured by providing a precise, step-by-step account of the research process for the judgment and evaluation of other researchers who may intend to conduct similar research. In addition, the researchers limited the textual reviews to reduce bias in conducting, analyzing, and coding the interviews and to enhance the validity of the data. Finally, in the process of collecting and analyzing the data, the researchers applied bracketing.

Ethics approval and consent to participate

Ethical committee as applicable

This study was conducted in terms of the principles of the revised Declaration of Helsinki, a statement of ethical principles directing physicians and other participants in medical research involving human subjects. Also, the study was approved by the Institutional Research Ethics Committee of FUMS, Fasa, Iran (Ethical code: IR.FUMS.REC. 1401.092).

Consent to participate

Prior to performing the interviews, all the subjects were informed about the objectives of the study, voluntary nature of their participation, data collection methods, reason for recording the interviews, role of the interviewer and the participants, and confidentiality and anonymity of the information. Subsequently, they were asked to sign the written informed consent form if they were willing to participate. The participants were notified that they would be free to withdraw from the study at any time.

Results

The participants’ mean age was 35.80 ± 5.52 (range: 26–43) years and the mean duration of infertility was 8.38 ± 1.65 years. All demographic characteristics of the participants are presented in Table 2.

Table 2.

Individual characteristics of the participants.

Participants	Gender	Age (years)	Duration of infertility (years)	Education	Job
P1	Female	39	8	Diploma	Employee
P2	Female	28	5	Bachelor	Housewife
P3	Female	41	7	Diploma	Housewife
P4	Female	33	10	Diploma	Housewife
P5	Female	39	8	Diploma	Employee
P6	Female	44	11	Diploma	Employee
P7	Female	30	8	Diploma	Employee
P8	Female	26	6	Bachelor	Housewife
P9	Female	28	7	Bachelor	Employee
P10	Female	31	9	Bachelor	Employee
P11	Female	39	10	Bachelor	Employee
P12	Female	37	11	Diploma	Employee
P13	Female	32	8	Diploma	Employee
P14	Female	40	10	Diploma	Employee
P15	Female	42	9	Bachelor	Employee
P16	Female	38	8	Bachelor	Housewife
P17	Female	29	6	Diploma	Housewife
P18	Female	37	7	Diploma	Housewife
P19	Female	43	9	Bachelor	Employee
P20	Female	41	9	Bachelor	Housewife
P21	Female	35	10	Bachelor	Housewife
P22	Female	40	7	Diploma	Housewife
P23	Female	39	6	Diploma	Employee

Analysis of the qualitative data resulted in three themes and eight subthemes. The three main themes were (1) overcoming identity crises (overcoming dysthymia, coping with unaccomplished motherhood), (2) respect for personal identity (respect for confidentiality, respect for beliefs, values, and attitudes, avoiding stigma and pity), and (3) compassion-focused therapy (sympathizing, mental and spiritual support, and enhancement of life skills). Table 3 outlines the themes and extraction subthemes.

Table 3.

Themes and subthemes extracted from content analysis.

Themes	Subthemes
Overcoming identity crises	• Overcoming dysthymia • Coping with unaccomplished motherhood
Respect for personal identity	• Respect for confidentiality • Respect for beliefs, values, and attitudes • Avoiding stigma and pity
Compassion-focused therapy	• Sympathizing • Mental and spiritual support • Enhancement of life skills

Overcoming identity crises

This theme consisted of overcoming dysthymia, coping with unaccomplished motherhood, and overcoming a sense of lack of feminine identity. Based on the participants’ experiences and views, overcoming a sense of not having an identity makes a significant contribution to maintaining dignity of women living with infertility. The participants stated that the mental tension of infertility and diminished prospects of motherhood aggravated their identity crises.

Overcoming dysthymia

Dysthymia is a smoldering mood disturbance characterized by a long duration (at least 2 years in adults) and transient periods of normal mood. The participants’ experiences showed that the severe stress and psycho-emotional tension caused by infertility led to depression, despair, frustration, and a sense of inadequacy in women living with infertility which aggravated their dysthymia. The occurrence of mental crises, including acute anxiety and depression, can impact all life aspects and social activities of women living with infertility. The participants in our study were trying to overcome this problem so that its effects would not affect other aspects of their lives.

According to one of the participants:

I was engaged in infertility treatments for nearly seven years, and thanks God, my problem was solved and I had a baby. Over those seven years, I didn’t let my life be affected by emotional stress, depression, or despair. I believe women living with infertility must not lose hope and give in to frustration but must preserve their feminine identity and fight to give meaning to it. Many of my infertile friends couldn’t cope with the mental and emotional crises caused by their condition and failed in their lives. A few of them even suffered serious mental disorders and sadly committed suicide. (Participant 16)

Coping with unaccomplished motherhood

As another subtheme of overcoming identity crises, coping with an unfulfilled sense of motherhood is essential to prevent women living with infertility identity crises from deterioration. Being deprived of motherhood has an adverse effect on women living with infertility feminine identity; it undermines their self-esteem and makes them feel inadequate and unvalued. Women living with infertility may be ignored or criticized by their spouses and relatives, and fail in performing their family and social responsibilities. Based on the participants’ views, to overcome their sense of lacking a feminine identity and experiencing motherhood, if their infertility treatments fail, women living with infertility can adopt a child to cope with their sense of unaccomplished motherhood. According to one of the participants:

I tried to have my infertility treated for almost 9 years. When I realized that all my follow-ups might be in vain, we adopted a baby from an orphanage. Now, I’m completely satisfied with my life. The sense of motherhood is a very pleasing feeling, and it made my family bonds stronger. (Participant 15)

Respect for personal identity

As another main theme of the study, showing respect for women living with infertility identity consists of maintaining confidentiality, respect for beliefs, values, and attitudes, and avoiding stigma and pity.

Respect for confidentiality

The participants’ responses indicated that one of the instances of disrespect for their dignity was the disclosure of their medical and clinical information. It is very important to women living with infertility that their medical records be treated as confidential; they have equal respect for their confidentiality concerning their dignity and regard it as one of their ethical and human rights. In many cases, violation of their confidentiality and disclosure of their medical information have caused serious emotional and psychological tension in women living with infertility, led to family issues, and undermined solidarity in their families. According to one of the participants:

Sadly, the treatment teams and doctors don’t respect the confidentiality of their patient’s records and share the patient’s medical or personal information with others without getting permission from the patients. (Participant 11)

Another participant stated that:

Some women easily tell friends and relatives about their infertility treatment and infertility issues. I don’t see how sharing this information can help women living with infertility, or how it concerns other people for that matter. This has happened to some of my friends; after they shared information about their infertility with other people, that information was misused, which led to serious family quarrels and, in some cases, divorce. (Participant 14)

Respect for beliefs, values, and attitudes

Showing respect for an individual’s beliefs, values, and attitudes indicates respect for their human dignity and vice versa. According to the participants’ experiences, to cope with their infertility-related problems, women living with infertility deeply rely on certain principles, beliefs, and values, and expect those beliefs and values to be respected by others. According to one of the participants:

Unfortunately, I have often been treated with contempt by people I know and society. It’s not my fault that I can’t have a baby. Why should they see me as an incompetent and worthless person and belittle my dignity. They even disrespect my fundamental beliefs and values and tell me I’m not going to have a baby by praying and giving to charity. (Participant 15)

Avoiding stigma and pity

Another subtheme of respect for personal identity is avoiding stigma and pity. Caregivers, families, and the society must avoid all forms of pitying behaviors, undue sympathy, and inappropriate labeling toward women living with infertility as it undermines their dignity and subjects them to severe emotional and psychological tension. One of the participants stated that:

When other people look at me with pity, it bothers me. They have no idea how their behavior hurts me. This kind of pitying behavior is typical of well-meaning friends. Sometimes, this pity is much worse than an insult and is a blow to your dignity. (Participant 9)

According to another participant:

Unfortunately, sometimes, at get-togethers, people use insulting labels to refer to women living with infertility like me. They say stuff like, “The poor thing can’t have a baby,” “She is barren,” or “What worth does her life have?” These insulting behaviors are unbearable and make us experience more emotional tension. What have we done to deserve all this disrespect and improper labels? I’m just fed-up with all this and don’t know what to do. (Participant 17)

Compassion-focused therapy

This concept concerns being self-compassion, unprejudiced acceptance of oneself, and responding to perceived challenges and failures. The basis of compassion-focused therapy is to transform behaviors, thoughts, and factors from an external mode to an internal mode, as a result of which change an individual’s mind is relieved after exposure to these internal factors. This concept, which is defined as self-compassion and unbiased acceptance of responses to perceived challenges and failures, was found to have a strong connection with a wide spectrum of positive psychological characteristics.

In this study, the participants were looking for conditions and facilities that would help them improve their abilities and positive emotions, and directly and indirectly overcome their sorrows and sufferings.

Sympathizing

Sympathizing with and giving comprehensive support to women living with infertility together with listening to their sorrow without pitying them not only increases their hope and self-esteem but also makes this population feel that the people around them respect and value their personal identity and dignity. One of the participants stated that:

I feel proud and valued when my family and husband sympathize with me and patiently listen to my griefs. It gives me hope and makes me feel more optimistic about overcoming my infertility and being treated in the end. (Participant 10)

Mental and spiritual support

Another subtheme of compassion-focused therapy is proving women living with infertility with mental and spiritual support. According to the participants’ experiences, women living with infertility are threatened by severe mental tension and crises, which not only undermines their resilience but also prevents them from performing their personal and social duties and eventually weakens solidarity in their families. Thus, giving women living with infertility mental and spiritual support is essential to empower them in coping with stress and strengthening solidarity in their families in the face of issues caused by their infertility. According to one of the participants:

In my opinion, spiritual and mental support is the most essential part of compassion-focused therapy for women who are suffering from problems related to their infertility, especially in the long run. Unfortunately, no one considers the mental and spiritual needs of women living with infertility. People think that this type of support is proper only for the terminally ill, like those who have cancer. The feelings of frustration, severe mental stress, depression, and worthlessness are sometimes so unbearable, and I don’t think other patients experience them. (Participant 20)

Enhancement of life skills

As another subtheme of compassion-focused therapy in this study, enhancement of life skills was regarded by the participants as approach applied for enabling women living with infertility to adjust to themselves, others, and their environment. These skills teach one how to act in life, especially in difficult situations. To cope with their personal and identity-related challenges and crises, overcome their psycho-emotional tension, and have a stronger sense of self-adequacy and self-confidence, women living with infertility are advised to enhance their life skills, which include stress management, mental health, spiritual health, communication skills, and emotional strength. It is also important that the managers and policymakers in the healthcare system take measures to educate this population in life skills. One of the participants stated that:

Sadly, the healthcare system has no comprehensive and effective plans for teaching life skills to the members of the society, including the population of women living with infertility. As a woman who suffers from infertility, I don’t know what skills I need to cope with my problems. There aren’t any educational or skill development programs for women living with infertility, and this is a major issue in the healthcare system. I don’t know when someone is going to do something about it either. (Participant 18)

Discussion

This study was conducted to examine dignity of women living with infertility in Iran. Three main themes were extracted from the collected data, namely “overcoming identity crises,” “respect for personal identity,” and “compassion-focused therapy.” The women who were studied maintained that they could preserve their dignity by overcoming the identity crises caused by their condition, having their personal identity respected, and using coping strategies, such as compassion-focused therapy. Several other studies also report that, in crises caused by illnesses, individuals seek ways to preserve their dignity.^27,28

In this study, because of their infertility, the participants were under great social, cultural, and domestic pressure in their lives, which adversely affected their dignity. Despite their difficulties, they sought to protect their hurt dignity and preserve it. Thus, they needed to overcome the identity crisis generated by their infertility, which necessitated effective management of their internal emotions. One of those emotions was a diminishing sense of motherhood, following their failed attempts to have a child. Motherhood is defined as attending to and caring for one’s child, satisfying the emotional and psychological needs of the child, and feeling responsible for the child. ²⁹ Being deprived of motherhood due to infertility will diminish this sense in women. ³⁰ Accordingly, women living with infertility seek ways to keep the sense of motherhood alive in them.

Several studies have reported that to adapt and maintain equilibrium in their feelings, especially feelings they fear they may never experience, women living with infertility seek alternative strategies which can help them experience positive feelings and keep their identity.^31,32 In this study, adopting a child was one of the strategies which was employed by the women living with infertility to prevent loss of their sense of motherhood. The participants sought to experience motherhood through child adoption. Adopting a child not only gives women living with infertility a chance to experience motherhood but also reduces the mental and social tension they are exposed to as the result of their infertility and enables them to preserve their dignity.^33,34

The women living with infertility who were interviewed in this study also stated that the dysthymia and alienation they experienced as the result of the mental tension caused by their infertility prevented them from successfully coping with their identity crises, which in turn undermined their dignity. As such, they tried to overcome the dysthymia associated with their infertility and maintain their feminine identity, thereby preserving their identity. Infertility and the efforts made to treat it expose women to severe tension, one of the consequences of which is depression. ³⁵

According to the work by Li et al., ³⁶ women living with infertility, illogical belief that their life will not continue subjects them to varying degrees of depression. This depression is accompanied by feelings of guilt, which can undermine their mental health.

Cui et al. ³⁷ reported that many women living with infertility suffer from depression. Given the positive impact of self-confidence on reducing depression, counseling sessions designed to enhance self-confidence in women living with infertility can help reduce depression in this population. In addition, elevated self-confidence and reduced depression help the women living with infertility maintain their personal identity and human dignity. ³⁸ Thus, the women living with infertility decide to seek counseling to overcome depression and preserve their life satisfaction despite their condition is effective in maintaining their personal identity and human dignity.^35,39

The women living with infertility in this study believed that having their personal identity respected was one way to preserving their dignity in the face of their infertility-related problems. Women living with infertility perceive infertility as a serious threat to their personal identity and regard their attempts to overcome this issue and have a baby as a means to protecting their personal identity; they try to manage any barriers to seeing their personal identity respected toward achieving their goal. ⁴⁰ Women living with infertility consider sharing information about their condition with individuals who are not involved in their treatment as a barrier to the preservation of their personal identity; therefore, they prefer not to discuss their infertility-related issues with individuals who are not medical experts and cannot help them overcome those issues. The ethics of patient confidentiality and patient privacy are among the most important principles of ethics in medicine, as stressed in ethics protocols. ⁴¹ Patients have the right to expect that the medical information about their illness and treatment procedures to remain confidential.^42,43 Disclosure of patients’ medical records can have an adverse effect on different aspects of the patients’ lives, aggravate their problems, subject them to despair, depression, aggression, and diminished self-confidence, and even result in family conflicts. ⁴⁴ Thus, negligence of patients’ confidentiality can undermine their personal identity.

In their study, Sankar et al. ⁴⁵ found that patients’ uncertainty about care provider’s respect for their confidentiality made them postpone their treatment or not to seek treatment at all since they regard breach of their confidentiality as revealing their hidden identity. Similarly, other studies report that patients’ fear of disclosure of their medical information causes them to indirectly search for a cure for their illness, especially via the Internet, to protect their confidentiality.^46,47 Maintaining confidentiality of women living with infertility, medical records by healthcare professionals, is essential to protecting their personal identity and encouraging them to pursue their treatment plans with peace of mind.

In this study, the participants held certain views and beliefs about their infertility and expected the people around them to respect those beliefs and values. In a stressful situation like infertility, individuals’ reactions are influenced by their beliefs and values; their perspective on infertility shapes their emotions and behaviors.^48,49 According to the work by Johanson, ⁴⁹ if women living with infertility follow values, such as spirituality, they can better cope with the tension of infertility. The participants tried to cope with the crisis caused by their infertility and maintain a positive attitude by putting their trust in God and praying. They regarded their infertility as an occurrence that was beyond their control and believed that praying to God and hoping for a divine remedy would help them. Similarly, in a study carried out by Khadivzade and Arghavani, ⁵⁰ the participants considered their infertility as a matter beyond their control and decided by God. They believed that their infertility would be treated if God wished and resorted to the God and saints to relieve their tension and enhance their chances of successful treatment; in other words, they relied on their religious beliefs to alleviate the stress caused by their treatment.

Another threat to the dignity and personal identity of women living with infertility, as mentioned by the participants of this study, was being pitied, stigmatized, and labeled by the people around them. Goffman ⁵¹ defines stigma as destroying the identity of an individual or a group by giving them a label ruining their reputation and making them stand out against their will. Individuals who are being stigmatized are not considered qualified to be accepted by society, which undermines their social status.

The stigma attached to infertility can turn private pain of women living with infertility into an explicit affair in society and put their personal identity at risk. ⁵²

Sometimes, stigma is rooted in perceived discrepancies between the unrealistic standards and the identity individuals imagine for themselves. Regardless of whether the stigma is manifested or hidden, individuals may experience discrimination. ⁵³ According to a study by Papreen et al., ⁵⁴ women living with infertility often experience a decline in their marital relationships and may even be abused by their husbands and despised by other members of their families. Their friends talk about their condition behind their backs and their relatives, for example, mother-in-law mistreat them because they are not able to give them a grandchild. These circumstances put women living with infertility at greater risk of stigmatization and discrimination, and undermine their self-value. ⁵³ Thus, women living with infertility who attempts to protect themselves from this social malady contribute to the preservation of their identity and social status.

In this study, the participants stated that, to restore their hurt dignity, they could use compassion to cope with the problems caused by their condition. Therefore, instead of blaming and criticizing themselves, they tried to empower themselves by enhancing their life skills and employing sources which could provide them with mental and even spiritual support. They preferred to spend time with individuals who sympathized with them and patiently listened to them for mental support, so that they could restore their hurt dignity.

However, self-compassion means caring and kindness toward oneself in the face of perceived difficulties to reduce one’s suffering; it is one of the important and powerful components in predicting people’s mental health, ⁵⁵ as it gives a person the ability to face painful thoughts and feelings (instead of avoiding them), and accept and solve the problem. ⁵⁶ The results of a meta-analysis also revealed that self-compassion therapy is related to psychological functions, such as positive mood, optimism, and overall well-being. ⁵⁷

According to the work by Hosseini et al., ⁵⁸ mental support of women living with infertility significantly reduces the stress and anxiety they experience as the result of their infertility and can have a positive impact on their treatment. Accordingly, strategies such as compassion-focused therapy can help the patients gain or maintain control over the situation in which they are and adjust to their problems more easily.

A study conducted by Zarastvand et al. ⁵⁹ indicated that compassion-focused therapy helped women living with infertility enjoy better marital self-regulation and avoid marriage burnout and self-criticism.

Araghian et al. ⁶⁰ reported that compassion-focused therapy can help eliminate marital conflicts. As women living with infertility condition makes them prone to marital conflicts, compassion-focused therapy can be an effective strategy to alleviating or removing those conflicts, improving their quality of life, and making their lives meaningful.^60,61 Compassion-focused therapy promotes self-compassion, self-acceptance, and rational judgment of oneself, thereby encouraging the individuals to display positive self-regulation in the face of life problems, have more self-confidence, and adopt a more positive perspective on life. ⁶² Indeed, compassion is an important construct in modifying the individuals’ reactions to distressful situations and helps them protect their dignity by mobilizing their sources of support. ⁶³

Limitations

This study investigated the perception of dignity of women living with infertility only in Iran. Differences in the dominant cultural, economic, and social conditions between Iran and other countries may restrict the generalizability of the findings of the study. Thus, it is suggested that similar studies should be conducted in other countries.

Strengths

This study is one of the few studies which investigated the dignity of women living with infertility using a qualitative approach, which makes it an innovative work.

Conclusion

The findings of this study suggest that dignity of women living with infertility is maintained when they can overcome their identity crises, have their personal identity respected, and receive compassion-focused therapy. The results of this study can be an effective solution to providing quality care to women by family doctors and health care providers since these people are the first level of care providers to these patients and they are familiar with their concerns, worries, and feelings. Also, knowing their care needs will help family doctors and health care providers to provide quality care. However, the results of this study can be helpful in setting general care policies for these people based on their spiritual, psychological, and physical needs. Finally, healthcare policymakers and administrators can use these findings to create a clinical environment where dignity of women living with infertility is properly maintained.