#91522: Couples with Infertility: Sociocultural Considerations

"African American" is a classification that serves as a descriptor; it has sociopolitical and self-identification ramifications. The U.S. Census Bureau defines African Americans or Black persons as "having origins in any of the Black racial groups of Africa" [29].

According to the U.S. Census, African Americans number 48.2 million as of 2019 [30]. By 2060, it is projected they will comprise 17.9% of the U.S. population [30]. This group tends to be young; 30% of the African American population in the United States is younger than 18 years of age. In 2019, the median age for this group was 35 years [161]. In terms of educational attainment, in 2019, 87.9% of those 25 years of age and older have a high school diploma [30].

As of 2019, 22.9 million Americans identified as Asian [138]. California has the largest concentration of Asian residents (6.5 million) followed by New York (1.8 million) [138]. This group had the highest growth rate between 2000 and 2019 (81%) of any racial/ethnic group [162]. Chinese Americans represent the largest Asian subgroup in the United States, and it is projected that this population will grow to 35.7 million between 2015 and 2040 [32,33]. They also have the highest educational attainment of any racial/ethnic group, with 54.6% of Asian Americans 25 years of age and older having a bachelor's degree or higher in 2019 [138].

"Asian" is a single term widely used to describe individuals who have kinship and identity ties to Asia, including the Far East, Southeast Asia, and the Indian subcontinent [34]. This encompasses countries such as China, Japan, Korea, Vietnam, Cambodia, Thailand, India, Pakistan, and the Philippines. Pacific Islander is often combined with Asian American in census data. The Pacific Islands include Hawaii, Guam, Samoa, Fiji, and many others [34]. There are more than 25 Asian/Pacific Islander groups, each with a different migration history and widely varying sociopolitical environments in their homelands [35].

Asian American groups have differing levels of acculturation, lengths of residency in the United States, languages, English-speaking proficiency, education attainment, socioeconomic statuses, and religions. For example, there are approximately 32 different languages spoken among Asian Americans, and within each Asian subgroup (e.g., Chinese), multiple dialects may be present [35,36].

The term "Hispanic" refers to individuals who self-identify as having origins in Spain or Spanish-speaking countries, such as Mexico, Guatemala, Peru, Ecuador, or the Dominican Republic [37]. In 2019, there were 60.6 million Hispanic persons in the United States [163]. The majority of the Hispanic population in the United States (63.3%) identify themselves as being of Mexican descent [38]. Approximately 27% of the U.S. Hispanic population identify as Puerto Rican, Cuban, Salvadoran, Dominican, Guatemalan, Colombian, Honduran, Ecuadorian, or Peruvian [38].

In 2010, Hispanic Americans represented 16% of the U.S. population; by 2019, this increased to 18% of the U.S. population [164]. It is estimated that Hispanics will comprise 31% of the U.S. population by 2060 [28]. In 2019, the three states (Texas, California, and Florida) with the largest Hispanic population also had the most growth [164].

The Native American population is extremely diverse. According to the U.S. Census, the terms "Native American," "American Indian," or "Alaskan Native" refer to individuals who identify themselves with tribal attachment to indigenous groups of North and South America [41]. In the United States, there are 574 federally recognized tribal governments [41].

In 2019, it was reported that there were 6.9 million Native Americans in the United States, which is approximately 2% of the U.S. population [41]. By 2060, this number is projected to increase to 10.2 million, or 2.4% of the total population [41].

In general, this group is young, with a median age of 31 years, compared with the general median age of 37.9 years. As of 2019, the 10 states with the greatest number of residents identifying as Native American are Arizona, California, New York, Alaska, Oklahoma, New Mexico, South Dakota, Texas, North Carolina, and Montana [U.S. Department of Health and Human Services, Office of Minority Health, 2022]. In 2019, this group had the highest poverty rate (24.1%) of any racial/ethnic group [41].

As noted, infertility is predominantly constructed as a women's disorder despite the fact that about half of all cases involving an inability to conceive are due to male factor infertility [166]. Because reproduction has been placed solely in women's realm, men are often excluded from discussions of infertility and reproductive care has been feminized [139]. In general, women who are childless are viewed as social anomalies in Western cultures; the same is generally not true for men [53].

A woman who is diagnosed with infertility is often viewed as flawed or tragically broken; women who voluntarily opt not to have children are often seen as selfish and uncaring [53]. In non-Western countries, hyperfertility is considered a more pressing issue, as policymakers are more concerned with rapidly growing population rates [54,55]. When infertility in the non-Western context is discussed, it is conceptualized as "barrenness among plenty" [55]. In a similar vein, social class impacts this view of hyperfertility in Western cultures. In the United States, poor women tend to be viewed as overly fertile and irresponsible, while more economically advantaged women are depicted as not being able to have children due to medical reasons [51].

Social problems do not emerge within an objective vacuum [56]. Instead, people make assertions and shape their views about certain conditions by typifying or depicting the nature of the social problem (e.g., large and growing, the result of negligence) [56]. Sangster and Lawson conducted a content analysis of 157 news articles about infertility published in 2012 in Canada [47]. Half of the articles described infertility using alarm terminology, depicting it as a public health concern that warranted consternation [47]. In a study examining women's perceptions of the risk of infertility, women who read more articles about women who became pregnant in their late 30s overestimated the risk [57].

Another way social problems are characterized is by tracing the cause(s) of the problem and identifying solutions. Slightly more than 40% of the articles analyzed by Sangster and Lawson constructed infertility as the result of a choice to delay childbearing, and 46% of the articles portrayed in vitro fertilization as the recommended course of treatment [47]. In other countries, the media may link women's infertility to sexual promiscuity, abortion, or having children outside of marriage.

The language of infertility can also be a source of bias. Terms such as "barren" and "sterile" convey a level of inadequacy [48]. As discussed, Western societies tend to embrace the biomedical model of infertility. This in part stems from cultural values that emphasize individualism and personal responsibility. In general, Americans tend to believe that they will be able to overcome obstacles through will power and determination. In the case of infertility, technology and medicine are the main tools to "overcome" infertility [59].

How a condition is defined and the parties involved in creating that definition can give a glimpse of the underlying values. For example, in some states (e.g., Rhode Island) infertility is defined as the condition of being unable to get pregnant or to carry a pregnancy among a married couple [140]. This definition relies on heteronormativity, as women who are married in a heterosexual relationship fit more easily into the definition [140].

The process of diagnosing and treating infertility is largely private in the United States. As of 2019, 17 states require insurance coverage for infertility treatment [167]. However, in non-Western countries, infertility is considered a community tragedy, rather than an individual one, and it is experienced by all members of the community [60]. In some cultures, particularly in Asian families, not having children is an affront to filial piety and a disruption of the social security net [61].

Notions of womanhood and motherhood are intertwined, despite the progress women have made in academic and professional spheres and the advancements in medical technology allowing for greater reproductive freedom. It remains expected for women in both Western and non-Western societies to move through life as daughters, then wives, and finally mothers. Motherhood is the socially respected identity for women [62]. An inability (or unwillingness) to meet the "motherhood mandate" upsets the social order and signifies defectiveness [63]. In some cases, these norms are closely linked to religious beliefs. For example, some religions focus on motherhood (or parenthood in general) as a mandate and fulfillment of God's ordinance [168].

It is important to note that this supports social heteronormativity and the idealization of marriage [140]. These gender role expectations are developed and reinforced through the performance of gender (i.e., behaving in a way that meets gender role expectations). In an interview study of 40 women experiencing infertility, the participants reported being unable to participate in typical interactions with other women, because conversations often centered around experiences raising children [63]. As a result, the women felt the infertility had removed their ability to be mothers but also threatened their identity as women by impeding their ability to bond with other women over shared gender roles. In general, the participants felt that their inability to make the transition to motherhood resulted in others treating them as somewhat less of a woman and less of an adult [63].

Not being able to have children (when motherhood is desired) ultimately makes a woman feel incomplete, and this appears to apply across cultures. In a study of Chinese couples with infertility in Hong Kong, the women reported experiencing shame and not being considered a complete woman [62]. Many Chinese women derive their identity and womanhood from being able to have children, particularly sons [141]. A study involving Latina immigrant women revealed the belief that being a complete woman involves having biological children because it demonstrates that a woman's body is socially and sexually useful, versus being selfish and/or broken [64]. This may be tied to the Hispanic cultural concept of marianismo, which venerates the ideal woman as being a pure and sacrificial mother [65]. In Nigeria and Cameroon, women with infertility are regarded as incomplete because they are not able to transition to full womanhood and adulthood [55,66].

This theme of pronatalism is common in Western cultures. Pronatalist ideologies echo the "social, political, and moral values, attitudes, outlooks, and beliefs that shape society's interpretation of women's and men's social roles regarding parenthood" [67]. Specifically, these ideologies emphasize the inextricable link between a woman's identity and her ability to reproduce [67]. These values underlie the social structure and are also reinforced through governmental policies (e.g., income tax deductions) [45]. Despite common themes of choice and self-determination in Western society, the desire to have children is considered a natural instinct that every woman should have [51]. The belief that motherhood is a natural instinct has emerged in multiple studies [48]. The discourse on motherhood often depicts childless persons as selfish, materialistic, or child-hating [169]. An analysis of 327 Australian newspaper articles published between 2007 and 2011 found four categories of representations of childless women [170]. The first was "sympathy-worthy women," which included those women who were involuntarily childless and deserved pity. The second was "career women," or women who put their careers and ambitions first; women in this category were typically depicted as selfish. The third category was "reprimanded women." Depictions in this category were closely connected to "career women" and were described as irresponsible and negligent. The final category was "artifact of feminism," which attributed the choice to remain childless as a result of feminist ideology. Childlessness is often considered an acceptable topic of conversation, despite it being painful for couples experiencing infertility [51]. Constant questions regarding reproductive plans reinforce individuals' feelings of failure and of being judged as selfish [67].

Tying a woman's worth to her reproductive capabilities also exists in non-Western countries. In South Africa, for example, "the bearing of children is seen as an essential part of being a woman and of achieving success as one" [68]. A woman bears a great responsibility in producing izizukulwane, which is a term that means "generations." Therefore, children represent a continuation of the family—genetically, socially, and culturally [60]. In many cultures, children serve as a social security mechanism, a way to ensure that religious rites are performed for the dead, and a means to guarantee social status for families [69,70,71]. In Ghana, motherhood is considered essential to a woman's identity. Those who are not mothers tend not to be accepted, which leads to social exclusion. One Ghanaian research participant stated that having children was more important than having a husband [171]. The importance of having children is so important in some developing countries that a woman with infertility may be ostracized from her community, abandoned by her husband, and forced to leave her home [72].

The social construction of infertility, womanhood, and motherhood is influenced by the social construction of family. Despite the diversity of family structures in today's society, the conceptualization of a family as consisting of a married heterosexual couple and their biological children persists [73]. In other words, the nuclear family system is the standard [172]. In the United States, the notion of the family is organized around marriage, law, procreation, co-residence, and biologic relatedness [74]. Pronatalism emphasizes women's reproduction of their own children and the assumption of biologic relatedness in the definition of family [73,141]. The need for biological children in the family system is rooted in the perceived need to continue a genetic line. However, pronatalism does not appear to extend to racial and ethnic minority women, particularly those who are from low-income backgrounds [169].

The terminology used to describe any condition can have an impact on its perception. In English, the word "fertile" is defined as capable of producing, abundant, and prolific, while the term "infertile" means unfruitful, sterile, and unproductive. Although the term "barren" is not employed as often, it conveys negative images of starkness, sterileness, and emptiness [76]. Historically, women with infertility carry the stigma of some type of moral and spiritual failure [76]. In Nigeria, the term for infertility is rashin haifuwa, which translates as "lack of childbirth" [55]. This term is used regardless of whether a woman has had a child previously or not [55]. In Punjabi, the most widely spoken language in Pakistan, the term used to describe infertility (baanjh) literally translates to mean "barren" and is associated with negative connotations [77].

Medically, there are many potential causes of infertility. The three most prevalent categories are ovulatory disorders, fallopian tube patency problems, and problems with sperm and/or semen [78]. However, patients' perceptions as to the causes of infertility are often more complex and involve cultural and spiritual explanations. Lay perceptions about the causes of infertility can be generally organized into four categories: supernatural causes, fate/destiny, infections, social factors, and sexual practices and other environmental factors. Supernatural causes include evils spirits, witchcraft, black magic, and curses [55,79,80]. In one study, Kuwaiti women with lower literacy and educational attainment tended to blame their infertility on evil spirits and witchcraft, while their more educated counterparts cited biopsychosocial causes such as psychosexual factors, poor nutrition (i.e., inadequate vitamin intake), and marital problems [80]. In another study, 60% of the female participants from Saudi Arabia attributed infertility to an "evil eye" [142]. In a cross-sectional survey of adults from Pakistan, approximately 30% believed that evil spirits (jinns) were the cause of infertility and 40% attributed infertility to black magic [79]. In Indonesia, infertility is often attributed to supernatural causes, and polygamy is acceptable in cases of infertility [173]. In a study with 609 Lebanese participants, men were more likely to consider divorce, living separately, or a second marriage if their wife was infertile [174].

Religious and spiritual beliefs also play a role in lay persons' perceptions of the cause of infertility. In several studies, the most common lay explanation was that infertility was fate or part of God's will. In a study of women in Nigeria, many believed their infertility was rooted in God's plan [55,143]. In Pakistan, women reported believing that children are a blessing from God, with infertility reflecting a lack of piety or unworthiness [79]. In some Asian cultures, the inability to conceive children is believed to be the result of displeasing ancestors and/or gods [175]. Analysis of online discussion forums devoted to infertility in Romania found that some participants attributed their infertility to divine causes, ultimately to test their faith and to build their character [144].

Hindu women may believe that their inability to have children is due to karma (i.e., the result of actions in a previous life) [60]. In other cultures, individuals may believe infertility is the result of not fulfilling certain cultural rituals and/or displeasing one's ancestors [60].

Infertility has also been attributed to infections or uncleanliness. Some Nigerian women reported believing their infertility was caused by infection or the introduction of dirt or other substances into their uterus [55]. Certain cultures consider infertility to be the result of the man's and woman's blood not blending well together [81]. Diet is also believed to play a role in some cultures [145]. Other social explanations include women's use of contraceptives, past abortions, masturbation, or perceived promiscuous behaviors [55,145].

Unfortunately, women bear the brunt of the blame and assigned responsibility for infertility across cultures [70,77,79]. In some Middle Eastern cultures, many adhere to a "seed and soil" explanation of reproduction. According to this belief, the seed (semen) helps to create but the quality of soil (ovum, uterus) is responsible for conception, thus placing the responsibility for reproduction and infertility on women [176].

As a result, women who cannot conceive may be ostracized and stigmatized [55; 82; 146; 177]. Extended family members may also regard a woman's infertility as a breach in family loyalty [147]. Women with infertility may be excluded from certain cultural and social rituals [79]. In some cases, husbands are encouraged to divorce or take second wives [77,82,174]. A Bangladeshi proverb reflects this devaluing of women with infertility: "Even a fox or a dog does not eat the dead body of a childless woman" [83]. For men, infertility threatens their masculinity, and this may cause them to blame their partners. In many developing countries, the most viable "treatment option" for men is to obtain a new wife [84,85].

Help-seeking involves a pathway or series of formal and informal contacts individuals use to request assistance. Individuals' help-seeking patterns provide a window to their attitudes toward infertility and its underlying causes and treatment [86]. Four main types of help-seeking patterns are [165]:

The ways in which one seeks formal or informal assistance reflect culturally specific meanings and beliefs. The Cultural Determinants of Help-Seeking model posits that there are three major dimensions that influence how assistance is sought: perceptions and labeling, interpretations of meaning, and social context dynamics (Figure 1) [87].

THE CULTURAL DETERMINANTS OF HELP-SEEKING (CDHS) MODEL

Figure 1

Source Republished with permission of Springer Publishing Company, from Saint Arnault D. Cultural determinants of help seeking: a model for research and practice. Res Theory Nurs Pract. 2009;23(4):259-278; permission conveyed through Copyright Clearance Center, Inc.

Feelings of loss and grief are common among couples with infertility [149]. Four phases of the grief cycle have been identified: disbelief/denial, anxiety and loss of control, isolation and guilt, and resolution [90]. Some argue that women experiencing infertility undergo disenfranchised grief. The loss of a loved one is visible, openly acknowledged, and associated with clear rituals to facilitate the mourning process. However, women experiencing infertility typically cannot rely on social norms that guide mourning. As such, persons experiencing infertility often describe it as an invisible loss [179]. Even when persons experiencing infertility disclose their situation, they may not be met with the compassion and empathy that they deserve.

As discussed, many women feel they are to blame (a feeling that may be reinforced socially), and they struggle with the meanings of loss of motherhood and their identity as a woman. Women in West African cultures that highly value motherhood tend to experience greater sense of grief and psychological distress [150]. In qualitative interviews with women with infertility, the following themes emerged: sense of inadequacy, feelings of loss of personal control, anger and resentment, depression, loss of a dream of reproducing and being a mother, and grief [91]. The women also reported experiencing envy and jealousy upon seeing mothers with children [90,91]. These feelings often led to social withdrawal and isolation [91]. In a study of 152 women undergoing infertility treatment, a significant association was found between maternal identity centrality and experiences of grief [92]. In one survey study, women who were undergoing fertility treatment who had overinvolved family members who accompanied them to treatment experienced greater grief if a treatment failed compared with those women whose family members were not aware of the situation [151].

Men also experience grief as a result of being unable to reproduce and may feel their identity or masculinity is threatened [89]. Men who believe they are the cause of the infertility experience higher levels of psychological distress and social withdrawal compared to women or male counterparts who do not believe they are the cause [93].

Unsuccessful in vitro fertilization (IVF) has also been shown to trigger grief responses and coping strategies in couples with infertility [94]. Studies of patients starting IVF have found the strongest predictors of psychological distress to be passive and active coping, self-criticism, and dependency and intrusiveness [95].

Because they are not able to have children, couples may question the purpose of their marital relationship, which can result in marital distress [89]. Marital conflict and distress can be moderated by many variables, including the couples' educational level, length of marriage/relationship, age, and number of miscarriages [152]. Furthermore, the locus of control also plays a role in marital satisfaction. Couples who score higher on an internal locus control (e.g., the belief one has power to influence outcomes) tend to have higher marital satisfaction [152].

When couples have fertility problems, the National Collaborating Centre for Women's and Children's Health recommends both partners be informed that stress in the male and/or female partner can affect the couple's relationship and is likely to reduce libido and frequency of intercourse, which can contribute to the fertility problems.

(https://www.nice.org.uk/guidance/cg156 Last Accessed: June 10, 2022)

Strength of Recommendation: Expert Opinion/Consensus Statement

There has also been research indicating that the diagnosis of infertility can result in a marital benefit, defined as a strengthened and closer relationship [96]. It is important to enhance this effect, when possible. However, it is clear that a diagnosis of infertility and the subsequent stresses of treatment can result in marital discord, partially due to differences in coping and emotional adjustment. In a study of 48 married couples seeking fertility treatment, clear differences in husbands' and wives' approach to fertility treatment were evident [97]. The researchers found that women tended to be more invested and involved in the treatment process (e.g., more invested in having children, more interested in discussing the process, experienced greater loss of self-esteem) than men. The greater the husband's involvement and interest in the treatment process and the better the quality of marital communication, the more likely that the diagnosis and experience would result in a marital benefit [97]. The authors of this study concluded that couples in infertility treatment may benefit from counseling or therapy to increase husbands' involvement and interest in fertility treatment and improve communication within the marriage.

Impact on the marital relationship appears to occur across cultures. In a study of 250 couples in Iran, participants who were infertile exhibited low scores in areas of sexual satisfaction, marital satisfaction, and quality of life compared with their fertile counterparts [153]. In an Iranian study, researchers found a positive relationship between loneliness and emotional divorce (defined as feeling separated from each other), restlessness, and boredom [180]. Loneliness also predicted martial burnout. With emotional divorce, couples acknowledge there is a problem in the marriage, but continue with their marriage despite the fact the marriage is devoid of intimacy. This intensifies loneliness and marital burnout, perpetuating a cycle of blame and distrust [180]. In a study of couples in South Africa receiving infertility treatment, infertility-related stress was found to have an impact on the quality of communication, sexual satisfaction, intimacy, and overall dyadic adjustment [98]. The perceived cause (i.e., female or male factor) may also influence one or both partners' satisfaction in the marriage. In a study of Iranian couples seeking infertility treatment, female partners who attributed the infertility to a female factor experienced less marital satisfaction; in cases of male-factor infertility, wives reported lower sexual satisfaction [99]. Similar findings were reported by male partners. Coping strategies and perceived social acceptance play a part in perceived marital satisfaction, indicating that couples would benefit from psychotherapy, skills training, and support groups [100].

Individuals' attitudes toward infertility treatment are linked to cultural norms and belief systems. In the United States, as in most Western developed countries, infertility treatment largely refers to artificial insemination and assisted reproductive technology (ART), while in developing countries, infertility treatment often consists (particularly initially) of alternative treatments, such as herbal remedies [81]. ART is an area of medical specialty serviced by reproductive endocrinologists. It can be useful for achieving pregnancy in women with tubal infertility or ovulatory infertility, particularly when pharmacologic fertility treatments and lifestyle modifications are not successful. Additionally, certain male factors necessitate the use of ART. Both donor eggs and donor sperm can be used for insemination and ART procedures. In this section, the focus is on ART for the treatment of infertility. The first child born through the use of ART in the United States was born in 1981 [184].

In studies with South Asian couples with infertility, many felt that using donated sperm and eggs was unacceptable [69,105]. Donated sperm was perceived to be more problematic because the continuation of the male genetic line was highly valued [105]. Some ethnic/religious groups view sperm donation as analogous to adultery, and some believe it should be illegal [175]. In a study of 589 couples in Nigeria, about 7% reporting feeling that ART was "unnatural" [143]. In Islam, sperm donation may be likened to adultery, with the resultant child regarded as illegitimate [105]. Eggs donated by a family member (e.g., a sister) are often considered more acceptable [105]. The Christian commandment of "being fruitful and multiplying" has likely positively influenced the acceptability of ART among Christians [175].

The use of ART has increased substantially in the United States, with the number of ART cycles and the number of resultant live births tripling between 1996 and 2015 [106]. In 2018, 203,119 ART procedures were performed in the United States [184].

Despite these trends, racial and ethnic disparities persist. A review of the National Survey of Family Growth found that of the women who had accessed fertility treatment between 2006 and 2010, the majority (67.3%) were White [107,108]. Access to infertility services increases with higher education and socioeconomic status. In a 2020 study with 1,460 women seeking fertility treatment, 81.5% had an annual household income of more than $100,000 [185]. Racial and ethnic minority women also tend to wait longer to seek medical assistance for infertility compared with White women [13]. In the same 2020 study, African American and Hispanic women reported traveling twice as far on average for treatment compared with their White and Asian American counterparts [185]. Among racial and ethnic minority women, Asian American women are most likely to access ART while Native American Indian women are the least likely to access ART [155]. African American women are 20% less likely than White women to obtain fertility treatment [155].

Racial and ethnic disparities in access to fertility treatment are likely the result of several factors. One of the largest barriers to infertility services is the cost [109]. The average cost of an IVF cycle in the United States can range from $12,000 to $17,000 [156].

As of 2019, 17 states have passed insurance mandates to cover ART and other infertility treatments, and regardless of race and ethnicity, rates for ART usage are higher in states with insurance mandates compared with those without mandates [155,156,167]. However, there is evidence to suggest that these mandates have not ameliorated the differences in rates of infertility treatment by race or ethnicity and socioeconomic status [107]. For example, for African American and Hispanic women, rates for ART utilization remain lower than overall rates in states with insurance mandates [155]. Even with insurance, it is possible that some cannot afford co-payments or deductible costs [155]. Some studies looking at "equal-access" subpopulations, such as women in the military who have the same level and type of health insurance coverage, have found no disparities in use by race and Hispanic origin, particularly between non-Hispanic White and Black women, though Hispanic women still appear to use services at lower levels than non-Hispanic White women [107].

Another factor is the enduring stereotype of the hyperfertile racial minority woman. The myth that poor and minority women have too many children, for example, may impede racial/ethnic minority women from accessing infertility services due to the fear of being treated discriminatorily [111]. Related to this myth is the concept of "intensive mothering," which is the concept that the norm of motherhood is based on a White, middle-class, heterosexual standard. Those who deviate from this standard tend to experience negative treatment from service providers [109]. Some argue that the medicalization of infertility introduces a barrier that serves as a means of deciding who is "worthy" of becoming a parent [112].

Racial and ethnic minorities also tend to mistrust the medical establishment, resulting in lower usage of healthcare services, including infertility treatment [113,186]. Because reproductive technologies are relatively new, some racial minority women and men may be hesitant to use them because they equate the procedures with experimentation. A history of unethical and damaging experimentation and forced or coerced sterilization in racial/ethnic minority populations have contributed to a general distrust of the healthcare system and specifically of procedures related to reproduction [7,114].

According to the National Collaborating Centre for Women's and Children's Health, counseling should be offered before, during, and after investigation and treatment of infertility, irrespective of the outcome of these procedures.

(https://www.nice.org.uk/guidance/cg156 Last Accessed: June 10, 2022)

Strength of Recommendation: Expert Opinion/Consensus Statement

Counseling services for individuals and couples with infertility may be categorized as patient-centered, supportive, or therapeutic. Determining the best type of counseling will help to define the role of the practitioner.

Assessment is an ongoing process, and practitioners should assess several areas at the initial phase of contact and throughout the counseling process, including emotional state, mental health issues, factors affecting emotional response, and views regarding family, parenthood, and children [7].

Couples experiencing infertility may present with a variety of psychosocial issues, including [116]:

Other seemingly peripheral themes and topics may emerge over the course of caring for these patients. For example, family of origin concerns or topics related to the couple's history (e.g., gender roles, identity, communication, sex) may arise [95]. It is important to create a safe place for such discussions to take place [122].

Loss, disenfranchised grief, and mourning are also recurring themes. The role of anticipatory grief should be considered [123]. Anticipatory grief involves the mourning of a future loss, in this case, the impending loss of parenthood. As part of the mourning process, the couple is tasked with defining what this loss will mean. Because loss, grief, and mourning are experienced differently, each individual should be given the opportunity to articulate her or his loss [122]. Practitioners should validate that while the loss might be experienced differently, every experience is equally valid [122].

Feelings of blame and guilt often surface for couples with infertility [7]. As described, most cultures and societies place great importance on reproduction, with the responsibility largely falling to women to ensure parenthood occurs. Whether or not blame is explicitly or verbally assigned, the couple may internalize these feelings, which can have an adverse effect on communication and the marital relationship [7].

The extent to which the problem is a shared experience will be influenced by the extent blame is assigned and the emotional phases the couple progresses through. Some phases will not necessarily be negotiated by the couple as a team; they may be on different paths [124]. For example, one partner might want to continue to pursue treatment despite a history of failures, while the other partner wants to give up [124]. During this phase, one partner will unavoidably feel like he/she is going through the journey alone. Again, it is important to help each partner understand that while the path may be slightly different, each person's journey is equally important and authentic [3].

Infertility can trigger a variety of emotions, and individuals may be sensitive to how others perceive and treat them. Consequently, the terms that practitioners use should be selected carefully. For example, the word "sterility" should generally be avoided because it implies a permanent failure rather than an issue that can be overcome [128].

When working with racial and ethnic minority clients, clinicians should be mindful that many of the interventions used to address psychosocial issues that arise in couples with infertility are based on Western cultural norms. In the United States, obtaining counseling or therapy is generally viewed positively as a mechanism to promote insight and personal growth. Counseling and therapy are rooted in the ideals of personal responsibility, whereby one takes control of destiny and the external environment. The notion of the "self" is at the heart of individualism; however, individuals from other cultural groups may be more collectivistic or group-oriented. In these cases, "talking therapies" will be culturally dissonant, and this is exacerbated by the fact that topics such as infertility, sexuality, and intimacy are typically considered private [7].

Communication with couples regarding lifestyle changes is a vital step in improving the chances of natural conception. When there is an obvious disconnect in the communication process between the practitioner and patient due to the patient's lack of proficiency in the English language, an interpreter should be utilized. Frequently, this may be easier said than done, as there may be institutional and/or patient barriers. A study of low-income, immigrant Latino couples with infertility found that communication was a major issue, with language and cultural barriers resulting in patients having difficulty both in understanding diagnoses and treatments and in communicating their questions, concerns, and experiences [129]. Reproductive care visits in which the patient and provider spoke different languages (and a staff interpreter was used) are significantly less likely to contain documentation of the provision of education and counseling services than visits with language-concordant providers [130].

Cultural generalizations should be avoided [131]. Even professionals attempting to incorporate cultural knowledge and sensitivity into their practice may unwittingly apply cultural generalizations. For example, in one study, when fertility topics were raised, practitioners used generalizations about the Asian family and how marriage was preferred in Asian cultures and automatically assumed that children were highly valued. Treating cultural/ethnic groups as a homogenous category perpetuates misunderstandings and miscommunications [131].

Gender sensitivity is equally crucial. Practitioners should be mindful that men and women with infertility experience a different set of dynamics. Men tend to be ambivalent in seeking psychosocial counseling and may have more difficulty identifying and verbalizing their infertility-related emotions [132]. Practitioners should address these issues and acknowledge the differences in stressors and experiences [132].

Both men and women with infertility frequently feel marginalized, reporting an "invisible shame" that cloaks their lives [3]. Many are fearful that discussing how distressed they are in not being able to have children will upset their partner and therefore suppress their feelings [3].

Many educational resources and psychosocial interventions specifically target women. When working with men regarding infertility, it is important to be sensitive to their unique needs and experiences [133]. Informational brochures that address the psychosocial issues triggered by infertility and through infertility treatment may be provided. Interaction with other men going through similar experiences (e.g., a support group) may be helpful. Professionals should take steps to make personal contact with men rather than going through their wives or partners. Educational information should be provided to men prior to treatment, as it increases the likelihood of men engaging in the process [3,133].

Infertility has been described as a "matterpsychic" condition, whereby one cannot separate the medical, psychological, emotional, social, and cultural dimensions [188]. As such, interprofessional collaboration and practice is crucial to providing optimal care. Care plans should be synchronized and carefully coordinated among practitioners. In order to achieve this, a collaborative interprofessional team approach should be maintained, with every provider contributing their unique skills, competence, and knowledge. Physicians, nurses, psychologists, social workers, counselors/therapists, pharmacists, alternative and complementary practitioners, religious and spiritual advisors, and cultural experts all play a key role when working with women from diverse backgrounds experiencing infertility.

Interprofessional collaboration and practice is characterized as a process whereby multiple service providers representing different professional fields work together to provide comprehensive services to clients/patients in order to coordinate high-quality services across settings. It requires professionals to alter the way they practice—moving from working in a silo to working in a collaborative and trusting manner, sharing information, resources, and multiple perspectives to address the complex problems of clients and patients. Efficiency, cost containment, and measurable outcomes are key. The core features of interprofessional practice are sharing, interdependence, communication, and mutual trust and respect [189,190].

When working with persons and families from diverse backgrounds, cultural sensitivity and competency are crucial, and there is much overlap between cultural competency and interprofessional collaboration [191,192]. Both cultural competency and interprofessional collaborations require that professionals take time to critically reflect on the historical and sociopolitical factors that have impacted their professional relationships. By practicing cultural competency, interprofessional collaboration and communication can improve [192]. Both cultural competency and interprofessional practice foster sensitivity and awareness to alternative perspectives and value systems to challenge stereotypes and reduce prejudice [191]. Ensuring appreciation for various professional lenses can lead to improved patient outcomes and enhanced patient communication [191]. Those seeking fertility treatment require care and support not by a range of individuals (e.g., physician, nurse, psychologist), but a group of professionals who work collaboratively, bringing in supportive care and services in order to address the patient's biopsychosocial needs during and after assessment, diagnosis, and treatment [188,193].