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Original Article
189
Infertility S tigma: A Qualitative S tudy on Feelings and
Experiences of Infertile Women
Mahboubeh Taebi, Ph.D.1, 2, Nourossadat Kariman, Ph.D.3*, Ali Montazeri Ph.D.4, Hamid Alavi Majd, Ph.D.5
1. Department of Midwifery and Reproductive Health, School of Nursing and Midwifery, Shahid Beheshti University of Medical
Sciences, Tehran, Iran
2. Department of Midwifery and Reproductive Health, Isfahan University of Medical Sciences, Isfahan, Iran
3. Department of Midwifery and Reproductive Health, Midwifery and Reproductive Health Research Center, School of Nursing
and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
4. Health Metrics Research Centre, Iranian Ins titute for Health Sciences Research, ACECR, Tehran, Iran
5. Department of Bios tatis tics, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Abs tract
Background: Infertility s tigma is a phenomenon associated with various psychological and social tensions especially
for women. The s tigma is associated with a feeling of shame and secrecy. The present s tudy was aimed to explore the
concept of infertility s tigma based on the experiences and perceptions of infertile women.
Materials and Methods: This qualitative conventional content analysis s tudy was conducted in Isfahan Fertility and
Infertility Center, Iran. Data were collected through in-depth interviews with 17 women who had primary infertility.
All the interviews were recorded, transcribed and analyzed according to the s teps sugges ted by Graneheim and Lund-
man. The S tandards for Reporting Qualitative Research (SRQR) checklis t was followed for this research.
Results: Eight hundred thirty-six initial codes were extracted from the interviews and divided into 25 sub-categories,
10 categories, and four themes. The themes included “s tigma prole, self-s tigma, defensive mechanism and balanc-
ing”. S tigma prole was perceived in the form of verbal, social and same sex s tigma. Self-s tigma was experienced
as negative feelings and devaluation. Defensive mechanism was formed from three categories of escaping from the
s tigma, acceptance and infertility behind the mask. Two categories; empowered women and pressure levers, created a
balancing theme agains t the infertility s tigma.
Conclusion: Infertile women face social and self-s tigma which threatens their psychosocial wellbeing and self-es teem.
They use defensive response mechanisms and social support to mitigate these eects. Education focused on coping
s trategies might be helpful agains t infertility s tigma.
Keywords: Female Infertility, Infertility, S tigma, Qualitative S tudy
Citation: Taebi M, Kariman N, Montazeri A, Alavi Majd H. Infertility s tigma: a qualitative s tudy on feelings and experiences of infertile women. Int J Fertil S teril.
2021; 15(3): 189-196. doi: 10.22074/IJFS.2021.139093.1039.
This open-access article has been published under the terms of the Creative Commons Attribution Non-Commercial 3.0 (CC BY-NC 3.0).
Received: 1/November/2020, Accepted: 26/December/2020
*Corresponding Address: P.O.Box: 1996835119, Department of Midwifery
and Reproductive Health, Midwifery and Reproductive Health Research
Center, School of Nursing and Midwifery, Shahid Beheshti University of
Medical Sciences, Tehran, Iran
Email: n_kariman@sbmu.ac.ir Royan Ins titute
International Journal of Fertility and S terility
Vol 15, No 3, July-September 2021, Pages: 189-196
Introduction
Infertility and subfertility aect a signicant propor-
tion of human beings (1). Infertility is dened as failure to
achieve clinical pregnancy after 12 months of regular un-
protected sexual intercourse. In general, 8 to 12% of cou-
ples of reproductive age suer from infertility worldwide
(2). According to a World Health Organization report,
more than 10 percent of women are aected by infertility
(1). In addition to the medical problems, infertility can
cause numerous personal and social problems. It can be
seen as a developmental crisis (3). Infertility can have
damaging social and psychological consequences from
exclusion and divorce to social s tigma that leads to isola-
tion and psychological dis tress (4).
Although infertility aects both sexes equally, it is
women who are mos t frequently blamed (5). This causes
infertile women to feel guilty and threatens their self-
es teem. Thus, infertile women experience greater psy-
chological s tress than infertile men, and they are often
s tigmatized for being infertile and being childless (6).
Many women experience infertility as a s tigma. Although
it seems that infertility s tigma is likely to be greater in
developing countries, infertility has been s tigmatized in
both developed and developing countries (7, 8).
Infertility s tigma is associated with the feeling of shame
and secrecy (9, 10). S tigma is dened as a negative feel-
ing of being dierent compared to others in society and
being contrary to social norms (11). If infertility is ex-
Int J Fertil Steril, Vol 15, No 3, July-September 2021 190
perienced as a s tigma, it has the potential to deprive the
infertile person of social support and cause depression,
anxiety and s tress (4, 12), feelings of guilt (13) and re-
lationship problems (5). It may also cause psychological
dis turbance, decreased self-es teem and self-ecacy, and
a tendency toward self-s tigma (14). Infertility s tigma and
its related social pressures inuence all the dimensions
of women’s lives and well-being. Qualitative s tudies can
provide more in-depth unders tanding of infertility s tigma
and can help develop more eective interventional s trate-
gies. Due to the limited number of qualitative s tudies in
this eld, this s tudy was conducted to explore the feelings
and experiences of infertile women regarding infertility
s tigma.
Materials and Methods
Design and data collection
This s tudy is a qualitative content analysis conducted
in Isfahan Fertility and Infertility Center, Isfahan, Iran.
Women with known infertility who were under infertility
treatments participated in the s tudy. The inclusion criteria
consis ted of having primary female infertility and absence
of any psychological disorders. Participant’s likelihood of
withdrawing from the s tudy was considered as the only
exclusion criterion. Purposive sampling was carried out
from 2019 to 2020 to ensure maximum variation in terms
of age, education, occupation and infertility duration. The
present article adheres to the EQUATOR guidelines of re-
porting research using the S tandards for Reporting Quali-
tative Research (SRQR) checklis t (15).
Twenty-one women were asked to participate in the
s tudy of which four refused because they were not inter-
es ted in the subject or had a busy schedule.
A private and comfortable room was provided in the
center and women were free to choose the place of the
interview. All the participants preferred the private room
in the center for their interviews. Semi-s tructured face-to-
face interviews were conducted to assess the perceptions
of women about infertility s tigma. The researcher used
interviewing skills to provide an intimate and comfortable
atmosphere for the participants and helped them express
their experiences of infertility s tigma. All the interviews
were conducted by the rs t author (M.T); a researcher in
the eld of infertility, and qualitative research. Two pilot
interviews were conducted to improve the ques tion guide.
Interviews were organized based on the research ques tion
and the data from the literature review. The interviews be-
gan with open-ended ques tions such as “How did you feel
about your infertility?”, “How did infertility aect your
life?", and “Did you experience any special treatment
because of your infertility? Probing ques tions such as
“How?”, “What do you mean?” and “Please explain
more on this issue” were asked to elicit further informa-
tion. With the progress of the s tudy, some direct ques tions
were added to the interviews such as “Have you expe-
rienced labeling because of your fertility problem?” and
“Do you feel any social pressure because of your fertility
problem?”
In-depth interviews were continued until data satura-
tion was reached; meaning that no new meaning unit was
extracted from the interviews. The duration of the inter-
views varied between 30 to 45 minutes. All the interviews
were voice recorded and then transcribed as soon as pos-
sible after the interview. The feelings and emotions of the
participants during the interviews also were noted.
Data analysis and trus tworthiness
Conventional content analysis using the Graneheim and
Lundman method was applied throughout the data col-
lection (16). Transcription, analysis and coding of each
interview was done before the beginning of the next in-
terview. The contents of the interviews were completely
transcribed. Transcripts were read several times to gain
unders tanding and identify initial categories of meaning
and codes. Codes, sub-categories, categories and themes
were derived from the transcripts. Combinations of relat-
ed initial codes were labeled to form sub-categories and
categories. Finally, the latent meaning of the text and the
main themes were developed until consensus between the
researchers was reached and the concept of s tigma in in-
fertile women was fully described.
Trus tworthiness of the data was determined as sugges ted
by Guba and Lincoln (16). To es tablish internal validity,
transcripts were reviewed immediately after they were
made. Adequate time was assigned to data collection, and
the rs t author had prolonged engagement with the s tudy
subjects. The transcripts and codes were shared with two
participants to ensure congruence between their experi-
ences and the s tudy ndings (member check). For depend-
ability of the data, external reviewers, who were not mem-
bers of the research team and were familiar with qualitative
s tudies, approved the units of meaning, codes, subcatego-
ries, categories, and themes and made sugges tions that were
considered in the nal analysis. The external reviewer was
asked to extract meaning units and initial codes of two in-
terviews. Then the percentage of agreement between initial
codes was calculated, which showed inter coder reliability
(ICR) was more than 90% (17).
Finally, to es tablish the external validity that demon-
s trates transferability, the authors provided a detailed de-
scription of the participants and their experiences, and the
research design. In addition, selected interviews, along
with codes and categories, were shared with two infertile
women other than the participants and they agreed that
these codes represented their real experiences (18).
Ethical consideration
All participants were informed of the s tudy purpose and
assured of the condentiality of their data and their vol-
untary participation. All the interviews were conducted in
a private and comfortable room. Informed written con-
sent was obtained from the participants that included con-
sent to recording their interview. The Research Council
Taebi et al.
Int J Fertil Steril, Vol 15, No 3, July-September 2021
191
and Ethics Committee of the Shahid Beheshti University
of Medical Sciences approved the s tudy (Approval ID:
IR.SBMU.RETECH.REC.1397.310).
Results
Seventeen infertile women participated in the s tudy.
Although data saturation was reached after 14 interviews,
the authors conducted three more interviews to ensure
saturation of the data. The mean age of the women was 32.88
years. The average duration of infertility was 4.25 years. The
characteris tics of the participants are shown in Table 1.
Table 1: The characteris cs of the parcipants (n=17)
Characteris tics of the participants n (%)
Age (Y) [32.88 ± 4.82]*
Less than 25 4 (23.5)
25-35 9 (53)
More than 35 4 (23.5)
Infertility duration (Y) [4.25 ± 3.71]*
Less than 5 9 (53)
5-10 6 (35.3)
More than10 2 (11.7)
Education
Less than diploma 3 (17.6)
Diploma 6 (35.3)
Academic 8 (47.1)
Employment s tatus
Housewife 12 (70.6)
Employed 5 (29.4)
*; Mean ± SD.
836 initial codes were extracted from the interviews and
categorized into 25 sub-categories, 10 categories and four
main themes. The four main themes that emerged during
data collection were identied as: s tigma prole, self-
s tigma, defensive mechanism and balancing (Table 2).
Theme 1: S tigma prole
The experiences of infertile women showed they have
perceived infertility s tigma. S tigma prole was experienced
as verbal s tigma, social s tigma and same sex s tigma.
Verbal s tigma
One of the dis tressful behaviors mentioned by all the
participants was verbal s tigma in the form of sarcasm,
humiliation, and use of oensive terms for infertility by
acquaintances.
A 32-year-old participant, with secondary education,
housewife, 10-year infertility duration said: “The old
people say that if someone doesn’t have a child, their house
is empty. They call them [OjaghKoor] (a humiliating
word that means the couple’s house is cold and spiritless).
Some say to me “how incapable you are that you could
not bring a child for your husband.”
Table 2: The theme, categories and subcategories of the inferlity s gma
concept
Themes Categories Sub-categories
S tigma prole Verbal s tigma Sarcasm and humiliation
Curiosity
Social s tigma Discrimination
Negative burden of infertility
Same sex s tigma Women agains t women
Sexism by women
Self-s tigma Negative feelings Bitter feeling of infertility
Sadness and regret
Fear and concern
Devaluation Incomplete woman
Transformation of values
Low self-es teem
Low self-ecacy
Defensive
mechanism
Escaping from s tigma Looking for someone to
blame
Jus tifying the infertility
Acceptance Getting along with the
problem
Unchangeable fate
Infertility behind the
mask
Secrecy
Silence
Balancing Empowered women Resilience
Optimism
Pressure levers Supportive/Unsupportive
husband
Peer support
Supportive family
Pressure from husband’s
family
Mos t participants encountered a huge number of curious
ques tions from their acquaintances such as why haven’t
you had children yet? Do you have a problem or does
your husband have any problems? These ques tions were
considered oensive and annoying in the eyes of the women.
Social s tigma
The attitude of community members and their negative
views toward infertility were pointed out by mos t
participants.
“From their type of look I can unders tand what they
are thinking. Infertility does not bother me at all, but
their looks do.” (34-year-old participant, with bachelor’s
degree, accountant, 5-year infertility duration)
“People think dierently about you. It looks like you are
dierent” (25-year-old participant, with primary school
degree, housewife, 8-year infertility duration)
Mos t participants were reluctant to use the term infertility.
They usually referred to it as “the issue”, “the problem”.
Infertility S tigma
Int J Fertil Steril, Vol 15, No 3, July-September 2021 192
"I do not like the word of infertility at all. I do not think
it is a good word at all.” (35-year-old participant, with
diploma degree, housewife, 9-year infertility duration)
Same sex s tigma
Mos t participants complained about being labeled by
other women.
“When my mother-in-low introduces me to others,
she says: she is my daughter-in-law, she is in our
family for 13 years but s till has no children. Please
pray for her. She wants to hurt me; she wants to
say that the problem is from my side.” (30-year-old
participant, with middle school degree, housewife,
9-year infertility duration)
Some participants said that: “They are women themselves,
they should unders tand other women’s problems, and they
have daughters themselves.” (33-year-old participant, with
doctoral degree, 1year infertility duration)
Some women experienced dierent types of sexism
from other women. A participant said: “The men in the
family have more empathy with me than the women.
My father-in-law is very kind and never asks a ques tion
to bother me, but women like their son in law more.”
(32-year-old participant, with diploma degree, 1year
infertility duration)
Theme 2: Self-s tigma
Sometimes infertile women internalize the process
of s tigma. We could identify at leas t two elements that
contributed to self-s tigma: negative feelings and devaluation.
Negative feelings
The experiences of some of the participants indicated
their suering and sadness. Repeated ques tions from
acquaintances would lead to psychological dis tress. The
negative feelings that these infertile women experienced
were expressed as bitterness, sadness and anxiety.
“I think that infertility is a disas ter. The disease itself
could be treated, but what happens in our society and
the way that others treat you, it is really bad. The fact
that everybody believes that it is your fault.” (30-year-old
participant, with middle school degree, housewife, 5-year
infertility duration)
Infertility and the outcomes surrounding it, including
the possibility of separation and remarriage of the
husband, occupied the women’s minds, and many of
them, despite having the support of their husbands, were
afraid that their marital lives would collapse. The idea
that not having a child would make their husband bored
with them and that they might look for someone else
always bothered them.
Devaluation
Participants believed that infertility was the reason for
their incompleteness and defect. Consequently, they had a
feeling of inferiority.
“I always think that, because I cannot get pregnant,
cannot have children, I am lower than others. This idea
really bothers me.” (34-year-old participant, with primary
school degree, housewife, 10-year infertility duration)
Sometimes these feelings of inferiority made them
transform their beliefs, and personal values and led to
deterioration in their self-es teem.
“My cousin was divorced when she didn’t get pregnant
after 13 years. I supported her. I used to say that having
a child is not the mos t important role of a woman. I did
not know that I would have the same fate. "(26-year-old
participant, with bachelor’s degree, housewife, 2-year
infertility duration)
“I’m not comfortable at parties at all. I don’t have a good
feeling. My self-es teem has really decreased. I don’t want
to be among others. I feel like I’m boring in comparison
to them.” (35-year-old participant, with diploma degree,
housewife, 9-year infertility duration)
These negative emotions reduced women's self-
ecacy, and they were not able to control their feelings
and emotions.
“I became very sensitive. My brother's wife became
pregnant. I did not want to see her during pregnancy at
all.” (37-year-old participant, with doctoral degree, 14
-year infertility duration).
Theme 3: Defensive mechanism
Infertile women unconsciously employed defensive
response mechanisms when they encountered the s tress of
infertility s tigma to protect themselves from psychosocial
harm. Women used a combination of defensive response
mechanisms, such as escaping from s tigma; acceptance;
and infertility behind a mask.
Escaping from s tigma
Avoiding acceptance of their infertility, and irrational
jus tications for infertility were some of the mechanisms
that participants used to escape from being labeled.
“Now that we are going to herbal therapy, it turns out
that my husband is weak! I told my mother-in-law, now
you see it was not my problem, but your son is weak.
(29-year-old participant, with diploma degree, housewife,
2-year infertility duration).
Acceptance
Over time, as the duration of their infertility lengthened,
some participants considered infertility undeniable and
tried to face it rationally and accept it as their fate.
“It could not be denied. But it has become really normal
to me and I am trying to get along with it. My grandma
always used to say, the life is not always in our favor,
Taebi et al.
Int J Fertil Steril, Vol 15, No 3, July-September 2021
193
so be patient and satised by what you get” (37-year-
old participant, with doctoral degree, 14-year infertility
duration)
Infertility behind the mask
Mos t participants were hiding their infertility from their
family and relatives, especially their husband’s family. By
remaining silent about their fertility problem, participants
escaped the judgments and pitiful looks of others.
“I don’t like anybody to know anything about this at
all. I don’t like to be looked on with pity. Whenever I’m
asked when you’re going to have children, I’d say I don’t
have time for children because I go to work. I come to the
center for treatment, but I don’t tell anybody” (42-year-
old participant, with mas ter’s degree, consultant, 3-year
infertility duration)
These participants always mentioned excuses such as
working and being busy, s tudying or pretending to have
decided not to have children when encountering curious
ques tions from others.
Theme 4: Balancing
Infertile women used various factors to balance the
psychological damage resulting from their perceived
infertility s tigma. This balancing was sub-divided into
two categories; empowered woman and pressure levers.
Empowered woman
Women endured and managed s tressful relationships
using a sense of humor, modifying relationships, and
ignoring the judgment of others to protect agains t the
psychological pressure caused by infertility s tigma.
“I turn it into fun, now. I say that my child doesn’t like
me to be his/her mom. He/she would come whenever
he/she wants. I won’t let them continue.” (32-year-old
participant, with diploma degree, housewife, 1year
infertility duration)
By performing artis tic, social, and athletic activities,
women tried to avoid negative thoughts and eliminate the
pressure of s tigma, so they could bring balance into their
lives.
“I always want to make others aware. I even have a
page on Ins tagram and I give information anonymously.
It is more for giving awareness to the society. These
activities amuse me in a way and are also good for my
spirit.” (34 year-old participants, with bachelor’s degree,
accountant, 5-year infertility duration)
Pressure levers
There are factors in the lives of participants that act
as positive or negative levers and modify the pressure
of infertility s tigma. Interviews showed that infertile
women received emotional support from various sources
including their husbands, families, peer groups, and, in a
limited number of cases, their friends. According to mos t
participants, husbands were the mos t important source of
emotional support.
“My husband has said that the problem is with him,
not me. He says all of this without putting any pressure
on me.” (32-year-old participant, with diploma degree,
housewife, 1-year infertility duration)
“In response to others, my husband says that I know
myself when is the right time to have a child. Right now,
my life is good, I don’t need children now.” (26-year-old
participants, with bachelor’s degree, employee, 2-year
infertility duration)
On the other hand, experiences of some participants
showed that the behavior of their husband was not
supportive, but, on the contrary, it was the source of
tension for them.
“I said now that I have this problem, we can go and get
a child from the orphanage, my husband objected, and he
said I want a child of my own, even with another woman.”
(33-year-old participant, with diploma degree, housewife,
4-years infertility duration)
Some participants mentioned that it is hard for others
to comprehend what infertile women are going through.
They believed that only women with the same problem
could unders tand them.
“I would like to talk with people who are similar to me.
When I talked with this friend of mine, who had adopted
a child, I felt really good. We could unders tand each
other pretty well. I was very happy when I came home
after meeting her. I did the house works; I liked to put on
makeup.” (34-year-old participant, with primary school
degree, housewife, 10-years infertility duration)
Some participants identied their family as a source of
support.
“My family comforts me a lot. They say do not have
s tress. Everything is going to be alright.” (34-year-old
participant, with diploma degree, housewife, 4-years
infertility duration)
Mos t participants cited their husband's family as a
source of tension and s tigma. Spousal family pressure
for remarriage or divorce was one of the concerns of the
infertile women.
“My husband’s sis ter tells him, think for yourself
while you are young. Go get remarried.” (25-year-old
participant, with primary school degree, housewife,
8-year infertility duration)
“They say we want grandchildren. Why don't you do
something? They ask which one of you is to blame for
infertility?” (36-year-old participant, with diploma
degree, housewife, 1-year infertility duration)
Discussion
The present s tudy is one of the few s tudies that focuses
on the perceptions and experiences of female infertility
s tigma. The research showed that the concept of infertility
Infertility S tigma
Int J Fertil Steril, Vol 15, No 3, July-September 2021 194
s tigma was perceived as verbal, social and same sex
s tigma. Self-s tigma was experienced as negative feelings,
and devaluation. In contras t, women used defensive
mechanisms in the form of escaping from s tigma,
acceptance and infertility behind the mask. They try to
make a balance between the sense of empowerment and
pressure levers.
The participants s tated that they had been verbally
humiliated by their acquaintances, being called s terile,
issueless and fruitless. Other s tudies have also mentioned
verbal sarcasm and using terms such as hollow, fruitless
tree, dried tree and barren land (9, 12, 19). Curious ques tions
from acquaintances were one of the concerns of infertile
women that could threaten their mental health and could be
associated with a wide range of psychological damages such
as anxiety, depression and low self-es teem (13, 20, 21).
Social s tigma referred to a situation in which infertile
women would face discrimination from others; a dierent
and compassionate look which was torturous to them.
Mumtaz. et al s tated that women perceived more s tigma
than men and that being s tigmatized was more painful than
being infertile (22). Furthermore, mos t of the participants
did not like the term “infertile”. Psychologis ts believe that
for such people, titles and labels should be used that do not
imply a aw; like using child free ins tead of childless (23).
Other women were the mos t considerable source of
s tigma. It seems that sometimes women are acting agains t
women. A s tudy in Niger showed that mos tly women were
the target of verbal and physical s tigma from the women
of their husband’s family (24). In mos t societies, even
advanced ones, having a child of your own is considered
a great privilege (25). Motherhood and having children is
the only way for women to raise their s tanding in the family
and the society (26). In traditional societies motherhood
is one of the important roles of women and those who are
not capable of performing this role are powerless in the
eyes of other women and would be humiliated (25).
According to interviews, women might internalize the
s tigma and see themselves lower than other women. These
women usually lose their self-es teem and are suering
from social isolation. Feelings of shame and inferiority
(27, 28), worthlessness and losing control, social isolation
and decreased self-es teem (5, 29, 30) have been reported
in other s tudies. Furthermore, women s tated that infertility
could threaten their marriage, this has been reported in
other s tudies too (5, 27). Fear of divorce and separation
has also been reported in Asian and African societies (5,
7, 9, 24, 31).
Goffman sugges ts that the individual sometimes
initiates a process of s tigmatization inside themselves
- internal or self-s tigmatization (11). Self-s tigma
refers to negative attitudes created in individuals by
themselves due to the conditions they have been put
through. One of the factors des tabilizing individual
identity is self-s tigma which seems to affect their
self-efficacy (32).
People do not react similarly to s tigma. Women used
defensive mechanisms agains t the tensions caused by
infertility s tigma. The mos t important of these were
hiding the infertility and infertility behind the mask.
Silence and hiding were reactions that have been reported
in other s tudies too (33, 34). Goman sugges ts that the
rs t s trategy for confronting s tigma is hiding it. Thinking
that the s tigmatized person will not be accepted they
try to reduce the intensity of the s tigma by hiding the
problem (11). However, it mus t be considered that, when
individuals hide their problem, they end up facing the
problem alone, which makes them more anxious. They
may also use inecient coping s trategies. The infertile
women’s fear that their secret might be revealed is likely
to increase tension, feelings of guilt and sadness, and
leave them open to psychosocial pressures (5, 8, 35).
All the women, regardless of age, educational level or
employment s tatus, had experienced forms of s tigma.
However, empowered women, regardless of education
and employment, were more successful in balancing
the psychological outcomes of infertility s tigma.
Kabeer mentioned that self-respect, self-ecacy and
psychological health could be improved by empowering
women (36). Therefore, the care team should consider
providing coping s trategies to women suering from
infertility s tigma.
Women mentioned some negative and positive sources
that could help them to adjus t to the pressures of infertility
s tigma. The mos t important source of support was their
husbands. The husband played the mos t important role
in defending his wife agains t the verbal and behavioral
pressures of others, especially the in-laws. Results of a
s tudy in Aus tralia also showed that a woman’s husband
and mother were the s tronges t, and the mother-in-law the
weakes t source of support for infertile women (35). In-
laws were one of the pressure levers also mentioned in
other s tudies (5, 6) and could be one of the main sources
of s tigma for infertile women.
One of the women’s s trategies for creating balance was
communicating with other infertile women. Peer groups
have been mentioned as an important source of support
for women with fertility problems. Improving social
relationships through the support of their peers could
increase fertility-related quality of life (37). Peer support
has a crucial role in therapeutic services, that should
be considered by healthcare providers (38). This can
complete the management of infertility and add mental
health perspectives to formal treatments.
People make decisions about their problems according
to their experiences (39), so interviewing women about
their experiences of infertility s tigma is valuable intself.
The interviewer has a long his tory of working with women
suering from fertility problems as a faculty member of
the midwifery and reproductive health department in the
university. She introduced herself fully to the participants.
The familiarity of the researcher with the subject of the
s tudy and cultural context might have helped participants
Taebi et al.
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195
to express their experiences and feelings better. This could
be a s trength of the present s tudy. The present s tudy is one
of the few qualitative s tudies that have undertaken an in-
depth inves tigation of infertile women’s experiences of
infertility s tigma.
Although the qualitative nature of the s tudy means that
its ndings are relatively context dependent, they are likely
to be generalizable to similar patient groups in similar
settings. A limitation of the s tudy is that the experiences
of women who were infertile but had not been referred for
treatment were not evaluated. This s tudy presents a clear
picture of infertility s tigma and could be a springboard
for further research related to infertility. It could also
be used for developing protocols for psychological and
counseling interventions appropriate for infertile women.
Conclusion
Infertile women confront dierent forms of s tigma that
can lead to devaluation and self-s tigma. On the other
hand, women use dierent defensive mechanisms and
try to make a balance between a sense of empowerment
and pressure levers. Health personnel who provide
services to infertile women should be aware of the s tigma
experienced by these women and its inuences on their
well-being. Education focused on coping s trategies might
be helpful agains t s tigma.
Acknowledgements
This qualitative s tudy is a part of a Ph.D. thesis
that was supported by Shahid Beheshti University of
Medical Sciences, Tehran. Iran. The researchers express
their gratitude to the care providers and the s ta of the
Isfahan Fertility and Infertility Center. We would like to
thank them for their cooperation as well as thank all the
participants who made this s tudy possible. There is no
nancial support and conict of interes t in this s tudy.
Authors’ Contributions
M.T., N.K., A.M., H.A.M.; Contributed to the concept
and purpose of the s tudy. M.T.; Participated in data
collection and evaluation, drafting and data analysis.
M.T., N.K., A.M.; Reviewed and were involved in the
qualitative data analysis. M.T., N.K.; Reviewed the rs t
draft of the manuscript. All authors edited the nal version
of the manuscript, participated in the nalization of the
manuscript and approved the nal draft for submission.
References
1. WHO. Infertility is a global public health issue. Available from: https://
www.who.int/reproductivehealth/topics/infertility/perspective/en/.
(26 Nov 2019).
2. Wasilewski T, Łukaszewicz-Zając M, Wasilewska J, Mroczko B.
Biochemis try of infertility. Clin Chim Acta. 2020; 508: 185-190.
3. Datta J, Palmer MJ, Tanton C, Gibson LJ, Jones KG, Macdowall
W, et al. Prevalence of infertility and help seeking among 15 000
women and men. Hum Reprod. 2016; 31(9): 2108-2118.
4. Slade P, O'Neill C, Simpson AJ, Lashen H. The relationship between
perceived s tigma, disclosure patterns, support and dis tress in new
attendees at an infertility clinic. Hum Reprod. 2007; 22(8): 2309-2317.
5. Hasanpoor-Azghady SB, Simbar M, Vedadhir AA, Azin SA, Amiri-
Farahani L. The social cons truction of infertility among iranian
infertile women: a qualitative s tudy. J Reprod Infertil. 2019; 20(3):
178-190.
6. Fu B, Qin N, Cheng L, Tang G, Cao Y, Yan C, et al. Development
and validation of an infertility s tigma scale for chinese women. J
Psychosom Res. 2015; 79(1): 69-75.
7. Karaca A, Unsal G. Psychosocial problems and coping s trategies
among Turkish women with infertility. Asian Nurs Res (Korean Soc
Nurs Sci). 2015; 9(3): 243-250.
8. Greil AL, Slauson-Blevins K, McQuillan J. The experience of
infertility: a review of recent literature. Sociol Health Illn. 2010;
32(1): 140-162.
9. Fledderjohann JJ. 'Zero is not good for me': implications of infertility
in Ghana. Hum Reprod. 2012; 27(5): 1383-1390.
10. Pacheco Palha A, Lourenco MF. Psychological and cross-cultural
aspects of infertility and human sexuality. Adv Psychosom Med.
2011; 31: 164-183.
11. Goman E. S tigma: notes on the management of spoiled identity.
New York: Simon and Schus ter; 2009.
12. Carter J, Applegarth L, Josephs L, Grill E, Baser RE, Rosenwaks
Z. A cross-sectional cohort s tudy of infertile women awaiting oocyte
donation: the emotional, sexual, and quality-of-life impact. Fertil
S teril. 2011; 95(2): 711-716. e1.
13. Donkor ES, Sandall J. The impact of perceived s tigma and
mediating social factors on infertility-related s tress among women
seeking infertility treatment in Southern Ghana. Soc Sci Med. 2007;
65(8): 1683-1694.
14. S ternke EA, Abrahamson K. Perceptions of women with infertility
on s tigma and disability. Sex Disabil. 2015; 33(1): 3-17.
15. O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. S tandards
for reporting qualitative research: a synthesis of recommendations.
Acad Med. 2014; 89(9): 1245-1251.
16. Guba E, Lincoln Y. Eective evaluation: improving the usefulness of
evaluation results throgh responsive and naturalis tic approaches.
1s t ed. San francisco: CA: Jossey-Bass; 1981.
17. O’Connor C, Joe H. Intercoder reliability in qualitative research:
debates and practical guidelines. Int J Qual Methods. 2020; 19:
1609406919899220.
18. LoBiondo-Wood G, Haber J. Nursing research: methods and
critical appraisal for evidence-based practice. 6th ed. S t. Louis:
Mosby Elsevier; 2006.
19. Dyer SJ, Abrahams N, Homan M, van der Spuy ZM. Men leave me
as I cannot have children: women's experiences with involuntary
childlessness. Hum Reprod. 2002; 17(6): 1663-1668.
20. Kearney AL, White KM. Examining the psychosocial determinants
of women's decisions to delay childbearing. Hum Reprod. 2016;
31(8): 1776-1787.
21. Luk BH, Loke AY. The impact of infertility on the psychological well-
being, marital relationships, sexual relationships, and quality of life
of couples: a sys tematic review. J Sex Marital Ther. 2015; 41(6):
610-625.
22. Mumtaz Z, Shahid U, Levay A. Unders tanding the impact of
gendered roles on the experiences of infertility amongs t men and
women in Punjab. Reprod Health. 2013; 10: 3.
23. Diamond R, Meyers M, Kezur D, Scharf CN, Weinshel M. Couple
therapy for infertility. Newyork: Guilford; 1991.
24. Dimka RA, Dein SL. The work of a woman is to give birth to
children: cultural cons tructions of infertility in Nigeria. Afr J Reprod
Health. 2013; 17(2): 102-117.
25. Younesi SJ, Akbari-Zardkhaneh S, Behjati Ardakani Z. Evaluating
s tigma among infertile men and women in Iran. J Reprod Infertil.
2006; 6(5): 531-546.
26. Alhassan A, Ziblim AR, Muntaka S. A survey on depression among
infertile women in Ghana. BMC Women's Health. 2014; 14(1): 42.
27. Fahami F, Quchani SH, Ehsanpour S, Boroujeni AZ. Lived
experience of infertile men with male infertility cause. Iran J Nurs
Midwifery Res. 2010; 15 Suppl 1: 265-271.
28. Gonzalez LO. Infertility as a transformational process: a framework
for psychotherapeutic support of infertile women. Issues Ment
Health Nurs. 2000; 21(6): 619-633.
29. Musa R, Ramli R, Yazmie AWA, Khadijah MBS, Hayati MY, Midin
M, et al. A preliminary s tudy of the psychological dierences in
infertile couples and their relation to the coping s tyles. Compr
Psychiatry. 2014; 55 Suppl 1: S65-S69.
30. Cizmeli C, Lobel M, Franasiak J, Pas tore LM. Levels and associations
among self-es teem, fertility dis tress, coping, and reaction to
potentially being a genetic carrier in women with diminished ovarian
reserve. Fertil S teril. 2013; 99(7): 2037-2044. e3.
Infertility S tigma
Int J Fertil Steril, Vol 15, No 3, July-September 2021 196
31. Anokye R, Acheampong E, Mprah WK, Ope JO, Barivure TN.
Psychosocial eects of infertility among couples attending S t.
Michael's Hospital, Jachie-Pramso in the Ashanti Region of Ghana.
BMC Res Notes. 2017; 10(1): 690.
32. Kato A, Fujimaki Y, Fujimori S, Isogawa A, Onishi Y, Suzuki R,
et al. Association between self-s tigma and self-care behaviors in
patients with type 2 diabetes: a cross-sectional s tudy. BMJ Open
Diabetes Res Care. 2016; 4(1): e000156.
33. Ceballo R, Graham ET, Hart J. Silent and infertile: an intersectional
analysis of the experiences of socioeconomically diverse African
American women with infertility. Psychol Women Q. 2015; 39(4):
497-511.
34. Ranjbar F, Behboodi-Moghadam Z, Borimnejad L, Ghaari SR,
Akhondi MM. Experiences of infertile women seeking assis ted
pregnancy in Iran: a qualitative s tudy. J Reprod Infertil. 2015; 16(4):
221-228.
35. Ried K, Alfred A. Quality of life, coping s trategies and support
needs of women seeking Traditional Chinese Medicine for infertility
and viable pregnancy in Aus tralia: a mixed methods approach.
BMC Women's Health. 2013; 13: 17.
36. Kabeer N. Resources, agency, achievements: Reections on the
measurement of women's empowerment. Dev Change. 1999;
30(3): 435-464.
37. Kiesswetter M, Marsoner H, Luehwink A, Fis tarol M, Mahlknecht
A, Duschek S. Impairments in life satisfaction in infertility:
Associations with perceived s tress, aectivity, partnership quality,
social support and the desire to have a child. Behav Med. 2020;
46(2): 130-141.
38. Dennis CL. Peer support within a health care context: a concept
analysis. Int J Nurs S tud. 2003; 40(3): 321-332.
39. Alavi NM, Alami L, Tae S, Gharabagh GS. Factor analysis of self-
treatment in diabetes mellitus: a cross-sectional s tudy. BMC Public
Health. 2011; 11: 761.
Taebi et al.