Background
Globally, infertility is perceived as a reproductive health issue, where more than 15% of the world’s population report that there is an issue of becoming pregnant naturally [
1,
2]. Researchers have described infertility as a sexually active couple not being able to fall pregnant after one year of regular sex without using any protection [
3,
4].
Being infertile is a challenging part of a woman's
lifeworld and for some decades identified with women in low-resourced areas in Africa [
5]. Fertility is highly regarded in many cultures within Ghanaian communities and, having children is among the most essential purpose of life-giving for women generally. Though both male and females are affected by infertility as a reproductive health problem, some recent research outcome have revealed that the focus on women is more apparent when compared to men. Women who suffer from infertility may endure considerable societal humiliation in many African cultures [
6,
7].
Invitro fertilisation treatments has become a powerful medical intervention in helping millions of people achieve their hopes of having a baby. For some women, treatment will not be successful, leaving many to cope with unresolved infertility [
8,
9]. The positive results of IVF treatment have been steadily increasing over recent years. Studies conducted in the United States showed that the overall clinical pregnancy rate was 40% per treatment cycle from 2017 to 2019 [
10,
11]. This means that 60% of women are unable to conceive successfully with each treatment cycle and 20% of women will fail to conceive after three attempts following IVF treatments [
12]. Such unsuccessful IVF treatments have a negative effect on the mental and social well-being of the affected women [
9,
13].
The question posed: ‘what are the lived experiences of women experiencing a single or repeated failure of embryo transfer following IVF [
12] and the common meanings assigned to this unique experience?’ remains unanswered in Ghana and certain parts of Africa.
Specifically in the literature search, limited studies have been found in Africa and none in Ghana that were specific to uncover the lived experiences of women following unsuccessful IVF treatment in the Ghanaian context. Furthermore, research on the distinctive meanings and detailed understanding of this intricate phenomenon in sub-Saharan Africa is inadequate [
14]. There is therefore a wide knowledge gap in literature on the subject under study. It is envisaged that the findings of the study may assist in developing indigenous, culturally relevant practical interventions to guide effective nursing practices in assisted reproductive technology/invitro fertilisation treatment (ART/IVF) services and support systems to help reduce the impact on their quality of life.
Methods
Study design
Heidegger’s hermeneutic phenomenology was utilized to unravel the
meanings women attribute to their life when undergoing IVF treatment and following unsuccessful IVF procedures. Heideggerian hermeneutics phenomenology sought to interpret the human lived experiences using language to provide both understanding and knowledge [
24,
25]. In order to respond to the main research question:
"What does it mean to be motherless-in-the-world-of-motherhood and experiencing IVF treatment failure?" Heidegger's Hermeneutic philosophy of phenomenology was deemed an appropriate philosophical stance.”
Study site
The site of the research was Ruma Fertility and Specialist Hospital located in Kumasi, in the Ashanti region. Ruma Fertility Hospital in Ghana is a cutting-edge specialist hospital primarily focused on providing first-rate infertility treatment services in Kumasi and beyond.
Invitation of the participants, sampling and sample size
Following, ethics approval, from the Faculty of Health Sciences Human Research and Ethics Committee (HREC) and all the research committees at the Fertility and specialist hospital, participants were identified and invited from the fertility’s clinic database if they met the inclusion criteria for this study. A purposive sampling method was used to invite six women who resided in the Kumasi metropolis, who were not successful following at least a cycle of IVF treatment prior to the initiation of the study.
Expression of rigor
To ensure the credibility of this study, we adhered to the criteria of rigor outlined by de Witt, Ploeg, and van Manen in hermeneutical phenomenological research, encompassing balanced integration, openness, concreteness, resonance, and actualization [
23,
26]. De Witt and Ploeg [
26] introduced 'balanced integration' as the first aspect of rigor, encompassing three essential elements: the articulation of philosophical principles, a well-defined methodological approach, and ensuring a balanced representation of participants' voices. In this approach, the study establishes a solid foundation by delivering clear and well-articulated philosophical concepts that seamlessly connect with the phenomenon under investigation. The study's philosophical underpinning aligns with Heidegger's hermeneutic philosophy, specifically focusing on the three modes of being:
authenticity,
inauthenticity, and
undifferentiatedness. This alignment is deemed appropriate and consistent with the research objective, contributing to the overall coherence of the study. Through the incorporation of participants' voices and a philosophical method, the study gives expression to the lived experiences of the individuals involved."
Openness and balanced integration were maintained throughout the research process, allowing scrutiny and harmonizing the phenomenon of interest. Concreteness was emphasized, ensuring clear writing and providing concrete examples to authenticate the study's context. Trustworthiness was reinforced through rich descriptions, quotations, member checking, prolonged engagement, peer review, and debriefing. Resonance aimed to integrate meaning into study findings, fostering a profound understanding for the reader. Actualization considered the future implications of participants' phenomenological interpretation, aligning appropriately with the study findings. The study effectively gives voice to the lived experiences of women through participant narratives and a philosophical approach.
Data collection process and procedure
Information was gathered through phenomenological dialogues that lasted between 40 and 90 min. Before the phenomenological conversation began, permission was obtained from the participants to tape record the conversation for the duration of the information generation process, to which they readily agreed. During the conversation a semi-structured phenomenological conversational prompt was used which consisted of keywords and prompts to help the researchers stay focus on the phenomenological conversations.
In total, two different phenomenological conversations with two follow-up sessions with each participant were carried out over a 24-month period. Prior to the first phenomenological conversation, the primary researcher engaged in an open-ended narrative conversation with two women with infertility problems. This assisted in preparing for the actual phenomenological conversation in various ways, including learning how to use the tape recorder, practicing silence, and dealing with interruptions.
The researchers' long-term involvement enabled them to re-examine crucial concerns and ponder on new areas of concern. The researchers gained comprehensive and information-rich material from the participants' lived-world through the two phenomenological conversations. This long-term involvement seems to increase the researchers' and participants' trusting connection [
27].
All phenomenological conversations and feedback sessions were originally conducted in the Twi language and subsequently transcribed verbatim into English. To extract conceptually relevant information, a series of translation techniques were employed. Initially, the content from phenomenological conversations and observational documents was transcribed verbatim in Twi. Subsequently, these Twi transcripts were translated into English. To ensure translation accuracy, an independent bilingual individual was tasked with translating the English version back into Twi. A comparison between these two versions was then conducted to verify the accuracy of the translation in relation to the original transcripts. The goal was to capture the similarities in the phenomenological conversations. The final English-translated conversations were utilized to identify emerging themes from the participants' narratives, thus informing the hermeneutic interpretive process."
Unravelling of the phenomenological conversations/data analysis
For this study, the researchers followed van Manen’s (1990) “six research activities” [
23] which briefly are:
1)
Turning to the nature of the lived experience: To be able to achieve in-depth meaning from the women’s shared lived experiences, we engaged with their narratives by highlighting sections of the transcribed phenomenological conversations and reflected on these through a personal journal. In particular paying attention to their tone of voice and physical gestures such as facial expressions, periods of silence and even them being tearful so that the essence of meaning in their lived-world was captured.
2)
Investigating experience as we live it rather than as we conceptualize it: Information was gathered not only through the participants’ phenomenological conversations, but also through writing, and observation. In staying true to Heidegger’s philosophical tenets of Dasein, being-in-the-world, the three existential modes of being (authenticity, inauthenticity, and undifferentiatedness), we started to identify the naïve themes of the participants’ experiences.
3)
Reflecting on the essential themes which characterize the phenomenon: As suggested by van Manen, themes can be isolated from the participant’s descriptions of experience by three different approaches which include: 1. The wholistic or sententious reading approach. 2. The selective or highlighting reading approach and 3. The detailed or line-by-line reading approach. To grasp the essential meaning of their experiences under study, these three approaches were applied at different times and to different narratives during the unravelling of the phenomenological conversations.
4)
Describing the phenomenon through the art of writing and rewriting: Through the process of writing and rewriting of the phenomenological conversations, meaning is revealed. Using a digital audio recorder, the phenomenological conversations were captured and transcribed verbatim as soon as possible.
5)
Maintaining a strong and orientated relation to the phenomenon: To be oriented in the study, the researchers made every effort to stay focused when analyzing the information by continually referring back to the research question to avoid ‘trivialities and falsities’ as described by van Manen [
23]. The lived experience themes identified were then used during the interpretation stage to assist in the selection of the relevant quotes from the participant’s transcribed phenomenological narratives.
6)
Balancing the research context by considering parts and whole: In this final stage of the research process, van Manen advocates that there is the possibility of the researcher losing sight of the phenomenon being studied and can get stuck in the information consequently losing its
meaning. Heidegger asserts that to comprehend the meaning of a conversational text, one must understand the meaning of its parts. However, understanding these parts is only possible through anticipating the overall meaning of the text [
22]. Every effort was made to balance the research context by considering parts and whole by continually scrutinizing the participant’s life-world and moving between parts of the phenomenological conversational text with that of the experience being shared. The interpretive analysis and participant feedback were completed when theme saturation was achieved, and no new lived experience themes emerged. As a result, the conversations were considered comprehensive, offering rich insights into the phenomenon.
Discussion
The study revealed that the women experienced existential faith. The women had high hope at the beginning of the treatment trusting they would be pregnant and give birth to a healthy child and belong to the mother world. Faith helped the women endure the frustrations and difficulties experienced during the IVF treatment by making meaning out of their distress (authenticity). The women spoke of their faith or religious practices as helping them survive and cope with their loss.
Quite remarkably, the findings above also resonate with the findings of a research inquiry conducted by Mosalanejad et al. [
28] and Boz and Okumus [
29]. It was known from their findings that majority of the women coped with their fertility problems through coming closer to God. A study by Chan et al. [
30] also found that, integrating spiritual care in psychosocial group intervention for women undergoing ART services promoted the psychological and spiritual well-being of the women diagnosed as infertile. Their result revealed that at the end of the group therapy, women described decreased levels of anxiety (
Angst) and physical distress significantly. We agree with the suggestions of Chan et al. [
30] on the need to incorporate religious and spiritual issues into current spiritual and body and mind therapies with the aim to improve spiritual care as well as the psychosocial needs of women pursuing IVF treatment.
Hope is a wish for a desired expectation [
28]. Hope is one of the most important factors in IVF achievement and women begin treatment with high hopes. For all the women the struggle to remain hopeful was difficult but in spite of their disappointment, they kept the hope alive. Previous authors have also shown that there is greater amount of anxiety and distress amongst women still hoping for pregnancy [
31‐
35].
The second concept in Heidegger's modes of existence is '
Being Inauthentic.' In this state,
Dasein confronts its current situation, which Heidegger describes as
fallenness (
Verfallen). This condition can prompt
Dasein to conform to societal expectations and norms without critically examining them, resulting in a tendency towards conformity and a diminished sense of individuality. Heidegger underscored the significance of acknowledging this fallen condition as a crucial step in reclaiming one's
authenticity and pursuing a more genuine existence (
Existenze) [
15,
22]. Heidegger termed the moment of disruption anxiety (
Angst) expressed as that mood in which
Dasein’s everyday way of
existence in the world is characterized by anxiety and fear [
19]. The overarching theme ‘Facing up to the
Angst’ became apparent in the women’s conversation as they shared their stories of failed IVF treatment. They explained how they struggled through diverse stages of the treatment to become pregnant. Consequently, the theme
‘Facing up to the
Angst reflects the ways in which anxiety clouded the women minds. Anxiety (
Angst) is also expressed as a common response for women with fertility problems who have experienced a failed IVF treatment [
29,
31,
35‐
38].
One of the most traumatic aspects of assisted reproductive technology (ART) is the waiting period for pregnancy results after embryo transfer. All the women in the current study reported that the greatest fear experienced in the IVF journey was the interim period post embryo transfer to determine the outcome of the procedure. This period of waiting as stated by the women causes’ great pain (
Angst) and described the experience as the most fearful and challenging moments for their
being-in-the-world of ART. Similar results have been reported in other studies [
31‐
36]. The study's findings also corroborate Hammarberg, Astbury, and Baker's assertion [
39] that the impact of IVF treatment is experienced during the anticipation of pregnancy results, even though the outcome is beyond the control of those undergoing the treatment.
Information gathered from the women’s narratives, indicate that the participants had concerns on the huge financial burden involved in one cycle of IVF treatment and making accessibility impossible. Many Ghanaian women are being denied access to ART services mainly due to high costs of the procedure. To make IVF services user-friendly, there is the need to reduce the cost and incorporate it in public funded facilities so that the average Ghanaian citizen can readily access the ART services.
Common to all, the women expressed guilt and self-blame about not being able to conceive. Enmeshed with guilt about the unsuccessful treatment were feelings of guilt about the cause of infertility and blaming themselves for the inability to become pregnant. Similarly, Mosalanejad et al. [
28] and Durgun-Ozan and Okumuş [
31] reported that the women had negative perspectives, considering all their desires and aspirations were lost and were dispirited.
Another distinctive theme that emerged from the women’s phenomenological conversation was the non-disclosedness aspect of IVF treatment. Mothers who underwent IVF treatment intentionally kept their treatment private to shield their children from potential stigma and to avoid societal misconceptions that linked IVF-conceived children with abnormalities. Some chose to conceal their IVF journey to escape gossip and unwanted attention. The secrecy surrounding infertility treatments stems from the threat they pose to the self-esteem and identity of women facing infertility, influenced by the associated stigmatization [
40].
Consequently, it is explicable that the participants decided to keep their treatment from the general public domain [
34]. Similar result have also been reported by Durgun-Ozan, & Okumuş [
31], Ying, Wu, and Loke [
35], Hammarberg [
36], Hammarberg, Astbury and Baker [
39], and Inhorn and Buss [
41]. This theme underscores the importance of creating a supportive environment that encourages open dialogue about infertility, challenging societal stigmas, and fostering a sense of community among those facing similar challenges.
The major lived experience theme, living with infertility (
being-in-the-world-of-motherless) includes descriptions about how the participants pursuing IVF treatment have been deprived of
authenticity of what every woman is expected to have concerning child bearing. The women felt that the opportunity of motherhood had eluded them. Motherhood is seen as an important societal role for women in the Ghanaian culture as such all the women grieved the loss of the motherhood role. In a pronatalist country such as Ghana who advocate for bearing children and subsequent motherhood, it is essential to reproduce to ensure the continuity of family blood line or humanity as proposed by [
41].
Implications of the study for clinical practice (IVF Carers)
From the women’s narratives, it appeared that their emotional needs were not being met and were not being cared for as expected. Based on the diverse emotions experienced by participants there is a need for healthcare staff to provide emotional support to help them cope with the situation.
It is also vital for the nurses and the counsellor at the fertility clinic to be trained and fully equipped with different ways to engage the women during the two weeks waiting period and after negative pregnancy test is disclosed. The interests of incorporating psychosocial support care into standard medical programme have also been documented as helpful [
33].
In addition, rendering culturally competent care remains vital in the nursing profession. Nurses and midwives must employ a high level of cultural understanding and awareness to meet the needs of the ever-revolving multicultural needs of infertility care.
The findings of this study offer valuable insights into the essential skills that healthcare providers need to acquire in order to better address the emotional needs of individuals undergoing fertility treatments. The findings guide the identification of necessary skills for effectively supporting women in the process of fertility treatment.
By gaining insights into the nuanced experiences and expectations of women facing infertility challenges, healthcare professionals can tailor their approach to provide more effective emotional support, fostering a more compassionate and patient-centered care environment.
Conclusion
In conclusion, this study employed Heidegger's philosophy to illuminate the experiences of Ghanaian women facing unsuccessful invitro fertilisation (IVF) procedures. The phenomenological conversations with participants underscored that infertility and its associated treatments significantly diminish the quality of life for women. Consequently, women engaged in IVF programs require sustained emotional support across all stages of treatment.
The pervasive sense of anxiety revealed through the hermeneutic interpretive process emphasizes the profound impact of IVF on women's quality of life. When confronted with the failure of IVF treatment, participants expressed a poignant belief that the opportunity to become a mother had eluded them. This emotional toll reflects the substantial disappointment and distress accompanying unsuccessful fertility interventions.
Notably, there is a pressing need to establish realistic patient expectations regarding IVF success rates at the outset of treatment. The study further illuminated that, women facing the prospect of future infertility, experienced distress and a sense of loss. The risk of societal and cultural pressures was evident as participants grappled with the decision to conceal their struggles with infertility and IVF treatments, highlighting the prevalence of a veil of secrecy.
The study's findings also shed light on the potential negative repercussions of idealistic reassurances regarding IVF success. While optimism is important, addressing these idealizations is crucial to aiding women in adapting to negative outcomes. Participants revealed grappling with feelings of disappointment, inadequacy, self-doubt, and a sense of incompleteness due to their inability to conceive and fulfill societal expectations of motherhood.
In essence, this study underscores the multifaceted challenges faced by women undergoing IVF in Ghana, emphasizing the necessity for ongoing emotional support, transparent communication about success rates, financial ramificatication and the importance of dismantling societal taboos surrounding infertility and IVF treatment. By acknowledging and addressing these complex emotional and cultural dynamics, healthcare providers can better support women navigating the intricate journey of infertility and fertility treatments.
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