|
| A) | having no children. | ||
| B) | a man's inability to produce high amounts of sperm for conception. | ||
| C) | reduced fertility with an extended period of non-conception (6 to 12 months). | ||
| D) | a woman's inability to become pregnant after 12 continuous months of attempting. |
It is important to define the terminology used to discuss infertility, as many variations in meaning exist and even the definition of infertility is complex. These variations may be influenced by the sociopolitical climate, technologic advances, and/or advances in reproductive health. Because of the varying definitions, prevalence estimates of infertility range from 1.8% to 47.7% [134]. Medically, infertility is defined as a woman's inability to become pregnant after 12 continuous months of attempting (i.e., unprotected sex with the same male partner) [4]. The World Health Organization defines infertility as a disease with associated disability and functional impairment [135]. It can be further classified as primary infertility, secondary infertility, impaired fecundity, or subfertility. Primary infertility refers to not having children and not being able to conceive after one year of unprotected sex; secondary infertility is the inability to conceive after at least one other pregnancy or live birth [5,135]. When defining infertility in women, the term is sometimes also loosely applied to those unable to carry a pregnancy to full term; however, the term "impaired fecundity" (i.e., infertility and failure to carry to term combined) is more accurate [6]. It is estimated that 7.4 million women in the United States are affected by impaired fecundity [39]. Subfertility is defined as reduced fertility with an extended period of non-conception— usually longer than six months but less than one year. In some cases, two individuals with subfertility may result in an infertile couple [7]. Ultimately, to define a problem as the inability to produce a certain outcome is problematic because it places less emphasis on the underlying risk factors, which can then cloud efforts to prevent or clinically manage the disorder [8].
| A) | 19.4% | ||
| B) | 23.7% | ||
| C) | 27.4% | ||
| D) | 33.3% |
The World Health Organization has estimated that there are between 48 million and 186 million people who have experienced infertility issues worldwide [42]. Worldwide, estimates for infertility range between 8% and 12% [135]. In parts of Asia, Europe, Africa, and the Middle East, the prevalence is higher, up to 30% in some places [135]. In the United States, 12.1% of women between 15 and 44 years of age have an impaired ability to carry a pregnancy to full term (impaired fecundity) [10]. In addition, 19.4% of women 15 to 49 years of age are classified as infertile (defined as 12 consecutive months of unprotected sex without resulting in pregnancy without a history of surgical sterility) [4]. The likelihood of infertility/impaired fecundity increases with age in women. An estimated 26.2% of women 40 to 44 years of age are considered infertile, compared with 23% of women 35 to 39 years of age and 11% of women 30 to 34 years of age [10].
| A) | Culture is static, but race is not. | ||
| B) | Race is equated with social class, and culture is only a symbolic token. | ||
| C) | Race focuses on political process, while culture emphasizes traditions. | ||
| D) | Race consists of a focus on physical traits or markers as a basis for classification; culture refers to patterns of life. |
Culture has been conceptualized as a diversity domain, characterized by having different value systems, norms, and social and behavioral patterns [43]. Specifically, culture refers to the values and knowledge of groups in a society; it consists of approved behaviors, norms of conduct, and value systems [15,16]. Culture involves attitudes and beliefs that are passed from generation to generation within a group. These patterns include language, religious beliefs, institutions, artistic expressions, ways of thinking, and patterns of social and interpersonal relations [17]. Culture can also represent worldviews—encompassing assumptions and perceptions about the world and how it works [18]. Culture has two components: the observable and the unobservable [52]. The observable include things such as language, customs, and specific practices, while the unobservable include beliefs, norms, and value systems. Culture helps to elucidate why groups of people act and respond to the environment as they do [19].
On the other hand, race is linked to biology. Race is partially defined by physical markers, such as skin or hair color [20]. It does not refer to cultural institutions or patterns, but it is generally utilized as a mechanism for classification. In modern history, skin color has been used to classify people and to imply that there are distinct biologic differences within populations [21]. Historically, the census in the United States defined race according to ancestry and blood quantum; today, it is based on self-classification. Racial characteristics are also assigned differential power and privilege, lending to different statuses among groups [22]. The American Anthropological Association defines race as "an ideology of human differences" which then "became a strategy for dividing, ranking, and controlling colonized people" [110].
| A) | Biology | ||
| B) | Traditions | ||
| C) | Social class | ||
| D) | Political process |
Ethnicity is also a complex phenomenon and has been defined in many different ways. Alba identified four components of ethnicity [23]:
Social class
Political process
Traditions
Symbolic token
| A) | Thai Americans | ||
| B) | Chinese Americans | ||
| C) | Japanese Americans | ||
| D) | East Indian Americans |
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].
| A) | The legalization of abortion and expanded sexual freedom | ||
| B) | The advent of artificial insemination and the rise in divorce rates | ||
| C) | The introduction of hormonal birth control and the rise of diagnostic laparoscopy | ||
| D) | Increased understanding of the conception process and expanded access to barrier birth control |
Prior to the 1960s, infertility was viewed as a condition with moral and emotional connotations [139]. However, infertility became a medical condition in the 1960s and 1970s as the result of significant events in the medical landscape [45,139]:
The introduction of hormonal birth control and associated ability to control reproduction
The rise of diagnostic laparoscopy and improved visualization of the female reproductive system
The increase in the number of trained gynecologists and obstetricians
The decline in fertility rates
| A) | Women without children are highly valued. | ||
| B) | Infertility is predominantly constructed as a women's disorder. | ||
| C) | Women diagnosed with infertility are often seen as selfish and uncaring. | ||
| D) | In non-Western countries, infertility is a more pressing issue than hyperfertility. |
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].
| A) | It impedes her ability to perform her gender. | ||
| B) | She is unable to adopt the socially respected identity of mother. | ||
| C) | She is unable to bond with other women over shared gender roles. | ||
| D) | All of the above |
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].
| A) | Lifestyle factors, male-female incompatibility, and depression | ||
| B) | Infectious disease, uterine abnormalities, and testicular cancer | ||
| C) | Endometriosis, polycystic ovary syndrome, and hormone imbalances | ||
| D) | Ovulatory disorders, fallopian tube patency problems, and sperm/semen problems |
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].
| A) | Fate/destiny | ||
| B) | Marital problems | ||
| C) | Supernatural causes | ||
| D) | Infections and other environmental factors |
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].
| A) | Burden of blame | ||
| B) | Social context dynamics | ||
| C) | Perceptions and labeling | ||
| D) | Interpretations of meaning |
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]:
Knowledge-seeking: Obtaining information to be better informed about the condition and solutions
Socio-emotional support-seeking: Engaging active strategies to cope with a range of emotions and stressors
Treatment-seeking: Initiating contact with and continuing to engage with health professionals
Non-medical solution-seeking: Employing nonmedical strategies to address issues
| A) | the stigma associated with help-seeking. | ||
| B) | an attempt to determine the source(s) of the event. | ||
| C) | identification of resources in one's personal social network system. | ||
| D) | an individual attaching positive or negative social significance to the event. |
After an event or feeling is perceived as abnormal (i.e., a symptom), meaning is attributed. Two types of attributions can be made: attributions of social significance or causal attributions. A social significance attribution occurs when an individual attaches positive or negative social significance to the event. For example, a woman who has difficulty conceiving might believe this is reflective of a personal failure or character flaw [87].
| A) | Family | ||
| B) | Social services | ||
| C) | Religious figures | ||
| D) | Institutional organizations |
The individual's social context will also affect help-seeking. The availability of resources in one's personal social network system (e.g., family, friends), community, neighborhood, workplace, and institutional organizations will clearly guide the type and amount of help obtained. This is subject to social rules of exchange, which define who can partake in the resources, under what circumstances, and when they should be reciprocated. Knowing someone who used a resource (particularly successfully) can influence help-seeking [148]. Collectivistic cultures (e.g., China, Mexico) are more likely to provide assistance to members in their group, and it is expected that the individual will rely first on her or his family before seeking outside help [87]. However, because of the stigma associated with infertility and fear of ostracism, members of these cultures may seek help outside of their usual resources (e.g., family members and community) [69]. Meanwhile, individualistic cultures expect that individuals will use personal resources (internal and external) before seeking outside help. If others help, this favor is expected to be reciprocated in a short period of time [87]. In the United States, many women will start the process of seeking help with their gynecologist/obstetrician, which is often the healthcare provider with whom they have most frequent contact [178].
| A) | Infertility only has a negative impact on a couple's relationship. | ||
| B) | Couples in infertility treatment are unlikely to benefit from counseling or therapy. | ||
| C) | The impact on the marital relationship appears to occur solely in Western countries. | ||
| D) | Better outcomes are likely when the husband is more involved in the treatment process. |
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].
| A) | Planning | ||
| B) | Ignoring or denying the problem | ||
| C) | Engaging in competing activities | ||
| D) | Managing one's emotional well-being |
Coping is the psychological process of reducing stress from social, personal, familial, and interpersonal factors. Several coping styles or patterns have been identified [101]:
Instrumental coping (problem-solving): Employing specific tools or strategies to help reduce the stress, including:
Planning (i.e., generating a plan of steps to move forward)
Suppression of competing activities
Seeking social support from friends, family, professionals, and paraprofessionals
Emotion-focused coping: Specific strategies to manage one's emotional well-being during the challenging situation
Active coping: Acknowledging the stress and attempting to mitigate the negative effects and outcomes
Avoidant coping: Ignoring or denying the problem
| A) | Access to infertility services increases with higher education and socioeconomic status. | ||
| B) | The majority of women who access fertility treatment in the United States are Hispanic. | ||
| C) | The use of assisted reproductive technology in the United States has decreased in the past 20 years. | ||
| D) | Racial and ethnic minority women tend to seek medical infertility treatment earlier than White women. |
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].
| A) | Cost | ||
| B) | Insurance mandates | ||
| C) | Mistrust of the medical establishment | ||
| D) | The enduring stereotype of the hyperfertile minority woman |
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].
| A) | Anger | ||
| B) | Legacy | ||
| C) | Dawning | ||
| D) | Immersion |
Individuals and couples with infertility experience a range of fluctuating emotions, and the level of intensity varies depending on the stage of grief and phase of the treatment process. Five emotional phases have been described for couples experiencing infertility [119]:
Dawning: Becoming aware of the problem
Mobilization: Seeking medical attention and confirming diagnosis
Immersion: Uncertainty during intensive testing and treatment
Resolution: Coming to terms with being unable to have a biological child, often with associated grief and mourning
Legacy: The ongoing process of coming to terms with the legacy of infertility and its implications
| A) | attribution of blame. | ||
| B) | the mourning of a future loss. | ||
| C) | resolution of ethical issues related to surrogacy. | ||
| D) | acknowledgement that each individual experiences loss differently. |
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].
| A) | Guided imagery | ||
| B) | Stress management technique | ||
| C) | Solutions-focused intervention | ||
| D) | Cognitive-behavioral intervention |
Many couples with infertility feel helpless and disempowered, and counselors should implement solutions-focused interventions that actively involve the couple so as to not exacerbate the already-existing feelings of passivity. For example, the couple may be advised to draw a road map and a satisfaction lifeline [95]. The road map can outline the available options and can be revisited and altered at any time. The satisfaction lifeline is a visual history of the relationship to the current time period. The couple places positive and negative events on the timeline, outlining their grades of satisfaction and how having or not having a child will affect their life satisfaction [95]. The goal is to assist the couple to see that not having a child does not necessarily mean their satisfaction with life and their marriage will be diminished.