One of the major effects of the contraceptive revolution is that it has afforded women the opportunity to plan when to have their first child. It can come as a shock to many couples who had used contraception conscientiously to find that over time their planned pregnancy does not occur. Research finds that couples are reluctant to talk about it to anyone and over time, their anxieties are accompanied by feelings of regret, stigma and social exclusion.
It was estimated in 2005 that one in six Irish couples had a problem conceiving a child. We explored this issue at the school of social work and social policy in Trinity College Dublin, in a longitudinal study of 34 couples over 27 months.
The research was funded by the Health Research Board. We examined the impact of infertility on couples' lives, their access to treatment, persistence through treatment and the outcomes of treatment.
One of the most successful treatments for infertility is IVF (in-vitro fertilisation), an assisted reproductive technology. However, its success rates vary. This article documents the experiences of the 10 couples who had at least one baby. Two other couples became pregnant and gave birth but their babies did not survive long after birth.
The study reveals that infertility treatment is best understood as a biomedical practice to be seen in the context of eventual access to IVF treatment. Couples went through a long series of diagnostic tests beginning with taking the drug Clomid to stimulate ovulation.
When this did not work, a post-coital test usually came next, followed by a laparoscopy to check for any abnormalities in the woman’s Fallopian tubes or uterus. When the latter was investigated, in two cases it revealed the need for tubal surgery and ovarian drilling.
In two other cases, endometriosis was detected and removed using laser surgery. Somewhat surprisingly, “sole male infertility” was later diagnosed in the case of three other couples; the women were then unhappy that they had been subjected to the discomfort of a laparoscopy before their partners’ fertility was checked.
One of the worst aspects of infertility treatment for couples was the waiting time, as the monthly reproductive cycle sets the context for both diagnosis and treatment. Intrauterine insemination (IUI) was tried by several couples, sometimes at their own request: this practice complied with Medical Council guidelines which state that "IVF should only be used after thorough investigation has shown that no other treatment is likely to be effective".
After a few months of investigative treatment, many women in our sample expressed a high willingness to endure whatever was necessary to have a baby. As one said: “You don’t really complain too much because you want to do anything to have a child so you don’t really think of yourself that much . . . you just go along with it.”
All the couples were paying for their treatment privately, they were highly motivated and were goal-driven. However, their belief in IVF did not diminish their emphasis on self-efficacy – they were determined to give the processes their “best chance” – it was also their “only” and “last chance” to have a child of their own. This level of motivation is certainly required by the women who, as the potential fathers admitted, carried the greater burden of treatment.
The IVF process required that a woman took a nasal spray every six hours, even during the night, for a six-week period of “down regulation”. This was followed by a series of abdominal injections that stimulate the ovaries to produce multiple eggs. Eggs were then recovered from ovaries while the woman was sedated. In some cases up to 14 eggs were collected.
During this time the father was asked to produce semen which was used to fertilise the eggs in vitro. However, the number of eggs collected was not an indicator of how many fertilised ova were suitable for transfer; often only one or two.
Not too surprisingly, IVF has been characterised as a series of hurdles; each stage of treatment can be experienced as a “success or failure in the pregnancy trail”. The transfer of the fertilised egg was not painful but could be undignified. Then the women had to wait another 16 days before taking a pregnancy test. For all the couples, this was the longest wait of all.
Women used vaginal gel as specified each day and dared not to do anything that would affect their chances of pregnancy. They became conscious of all bodily signs, dreading the arrival of a period.
Couples were determined not to be too excited in order to guard against huge disappointment. At the same time, they maintained a positive attitude as they believed it might affect the outcome. When women did not have a period, they often used several pregnancy testing kits to confirm they actually were pregnant. Many could not believe their luck that all their efforts had finally been worthwhile.
While fertility outcomes from IVF are dependent on many factors, these case-study findings of those who were successful reveal the following: five of the couples had male factor infertility, three had female-related factors while one couple had a combination of both factors. In the case of three couples, no specific factors were identified.
The majority of couples were in their 30s. However, only two couples got pregnant after their first IVF treatment cycle. Five couples had twin pregnancies. For the two couples whose babies died shortly after birth, the outcome was very traumatic after such a long journey. Some pregnancies were difficult and created many anxieties, but despite that the parents described it as a “precious time”.
We hope this study raises the issue of early diagnosis of fertility problems and earlier access to treatment. There is a need to increase public awareness and knowledge about infertility, its causes and its treatment, in order to reduce stigma and anxiety. It is also important that couples who seek treatment are fully informed of treatment procedures and outcomes.
Dr Evelyn Mahon FTCD is professor emeritus of the school of social work and social policy at Trinity College Dublin.
Assisted Reproductive Technology – IVF Treatment in Ireland: a Study of Couples with Successful Outcomes' by Evelyn Mahon is published in Human Fertility, September 2014.
