- Email: [email protected]
Couples' Experiences with In Vitro Fertilization
clinical studies Couples' Experiences with In Vitro Fertilization BARBARA J. MILNE, RN, MScN
In vitro fertilization (IVF) is one of the newest techniques for treatment of infertility. While the medical aspects of IVF have been extensively reported, little research has explored this procedure from the couple's point of view. In this descriptive study, 28 couples who had experienced at least one IVF procedure were interviewed. The results indicate that while IVF offers hope for infertile couples, the procedure, if unsuccessful, can be emotionally traumatic. In addition, the results suggest that comprehensive anticipatory information and emotional support are the primary needs of couples undergoing IVF.
Infertility, the failure t o conceive after 12 months of unprotected intercourse, affects 10-15% of North American couples.' While various forms of therapy are available for treatment of infertility, o n e of the newest and perhaps most controversial is t h e technique of in vitro fertilization (IVF). For a couple who has already undergone a multitude of tests and unsuccessful procedures, treatments, and, sometimes surgery, IVF may represent the couple's last chance of having their own child. However, the procedure requires a substantial investment of personal and monetary resources with only an approximate 15-30% chance of success.2
Accepted: December 1987
September/October 1988 JOCNN
RELATED LITERATURE
The number of couples in North America who are receiving IVF is rapidly increasing. A s a result, health professionals need to understand how IVF affects the lives of couples who undergo this treatment. While recent articles in the 1it e r a t ure have high 1ig h t e d t h e medical aspects of IVF,3-6 little research to date has explored this procedure from the couple's point of view. Understandably, couples enter an IVF program in an emotionally vulnerable state. According t o Link and Darling and Menning, who studied the emotional needs and dimensions of life satisfaction of infertile couples undergoing treatment, the stress of trying and failing to conceive for a number of
years has significant effects on individuals, relationships, and even careers7-' In addition, the process of diagnosing and treating infertility has a major impact on the lives of these couples.'o*" O'Moore et al. conclude that this impact is usually far greater when the treatment process is prolonged and unsuccessful,'2 which usually occurs with couples entering an IVF program. The problem of infertility alone often makes couples feel isolated from friends and family because of t h e strong social and cultural expectations to have children.* Couples undergoing IVF may feel particularly isolated. Strickland reports that because of the sensationalism and controversies surrounding IVF, couples might be reluctant to share knowledge of
347
their participation in this program As a rewith friends or re1ati~es.I~ sult, usual sources of comfort and support might be missing at a time when they were most needed, leaving these couples a t even more risk for emotional problems.
METHODS Purpose The purpose of this study was to answer the following questions: How is IVF experienced by couples who undergo the procedure? 0 What are the needs of these couples? 0
A descriptive approach, using
guided interview and participant observation techniques was chosen to answer these questions. Sample All study subjects were obtained from the IVF program at a large teaching hospital in Vancouver, British Columbia. Subjects were selected for the study if they were English-speaking, Vancouver residents, and had completed at least one treatment attempt of IVF. A treatment attempt corresponds with a one-month menstrual cycle.
Sample Twenty-eight couples were interviewed. The mean age of the husbands was 35 years and the mean age of t h e wives was 33 years. The majority were highly educated and of North American origin. These couples had been married an average of nine years and had tried to conceive for an average of six years. The majority had experienced more than one IVF attempt (n = 17), with five couples undergoing their fourth and last IVF cycles. Of the 28 couples, only two achieved pregnancy.
348
Procedure Couples were approached initially by one of the nurses on the IVF team and, if interested, were contacted by the author and invited to participate in the study. If the couple agreed, a joint interview with both partners was arranged at the couple’s home three weeks o r more after embryo transfer when the success or failure of the procedure would be known. Informed consent was obtained, and couples were identified by code number to maintain confidentiality.
RESULTS Couples were initially asked what words they would use to describe their overall experience. While a small number of couples (n = 6) used positive words such as “hopeful,” “exciting,” “interesting,” and “high tech,” the majority (n = 22) expressed strongly negative feelings. Words like “devastating,” “physically and emotionally draining,” and “heartbreaking” were used most frequently and demonstrate clearly the powerful impact of yet another failed attempt at pregnancy.
Instrument The interview guide consisted of six close-ended questions designed t o collect demographic data followed by a series of twelve open-ended questions about the IVF experience. These questions were designed to elicit the couples’ perceptions of both positive and negative aspects of the procedure, reactions of others, sources of social support, impact on lifestyle and marital relationship, and their ideas for improvement of the entire process. T h e interview guide was tested for content validity by medical and nursing experts who work with IVF patients and by two individuals known personally by the investigator who had undergone IVF. These latter two individuals also acted a s a pretest group for t h e interview guide.* The content of the interview guide was analyzed to identify persistent words, phrases, themes, and concepts central to the research topic. These were coded and developed into categories. These data were then tabulated and summarized using elementary descriptive statistics (averages and percentages). * A copy of the interview guide is available from the author. (See address for correspondence.)
While IVF offers some hope, the procedure may be physically and emotionally draining. Couples were also asked to identify the positive aspects of the 1VF experience. Four basic categories emerged: interactions with health personnel, hope, camaraderie with other patients, and outcome (for two couples). For those two couples for whom IVF was successful, the resulting pregnancy was seen as t h e most positive aspect of the program and well worth the overall investment. Couples were also asked to identify the negative aspects of the IVF experience. Again, four basic categories emerged: interactions with health personnel, characteristics of the procedure, outside influences, and husbands’ attitudes. Interactions with health personnel were cited as both the most positive and most negative aspects of the IVF experience by 15 of the 28 subjects. Nineteen of the couples mentioned some aspect of the IVF procedure itself as a negative aspect of the experience, and five
September/October 1988 JOG”
couples had concerns that were not associated directly with the procedure or personnel. In addition, couples were asked what part of the experience had been the most difficult for them. Fifteen couples identified t h e waiting period after the embryo transfer as t h e most difficult aspect of the experience. Couples were also asked if any previous experiences were similar to their IVF experiences. Eight couples compared the experience to a previous loss. Couples identified four major sources of support that emerged during the 1VF experience: each other (n = 19), relatives (n = 13), other IVF participants (n = 13), and friends (n = 9). Twenty-six couples received positive responses from their friends, colleagues, and relatives, and eight couples received negative responses. Three couples reported that they told no one of their experiences. When asked about effects of the IVF experience on their lives, 12 couples identified the wife’s life goals as being significantly affected by the IVF program. Twenty-three couples reported that the experience had a positive impact on their relationships, while five couples reported that the experience had a negative impact on their relationships. Despite the physical, emotional, and financial strains of IVF, 21 couples indicated that they intended to try again, and were already preparing for another attempt. Furthermore, of those couples who declined to undergo IVF again, four did so only because they had reached the trial limit (four treatment attempts) or the age limit. DISCUSSION
The most commonly cited positive aspect of the IVF experience
September/October 1988 JOCNN
I
I
I
The quality of couples’ relationshim with IVF team members i’s an important determinant in couples’ perception of the experience.
was couples’ interactions with certain members of the IVF team. Over one-half of the couples interviewed (n = 15) commented on the supportive and informative environment created by the IVF nurses, trust they felt in the staff, highly organized process that inspired confidence, and positive attitudes of everyone involved with the program. In addition to these general comments, the medical director of the program was singled out by 14 of the couples as being a major positive force in humanizing and personalizing the experience. With all other treatment options exhausted, the IVF program was seen as a ray of hope, however temporary, by 10 couples. Many couples indicated how privileged and excited they felt to have this opportunity. Despite knowledge of the low potential for success, couples felt that maybe they would be one of the lucky ones. The close friendship network that developed, primarily among the wives, was identified by nine couples as an unexpected bonus. Thirteen women sought out the opportunity to share their feelings and experiences with others going through the same procedure. This camaraderie was seen as a major source of support through a n emotionally difficult time. Paradoxically, t h e negative aspect most commonly cited (n = 15) involved interactions with health-care professionals associated with the IVF procedure. Those who had participated in the IVF program over several years
observed that the process had become increasingly impersonal and mechanical as the demand for the procedure and, hence, the demand on staff time had increased. This depersonalization was felt most keenly at the point when a treatment attempt failed and couples were actively grieving and in need of support. Other major concerns involved difficulties obtaining a satisfactory amount of information about procedures, laboratory test results, and drug side effects. Of the aspects of the IVF procedure that were identified as negative, the multiple injections and blood tests, ultrasounds, side effects of the drugs and anesthetic, time-consuming nature of the process, embarrassment associated with sperm donation, and the overwhelming number of instructions were all perceived as necessary but uncomfortable aspects of the treatment process. Those couples who had undergone more than o n e IVF experience commented that their anxieties about the procedure diminished decidedly with successive trials. As reported, five of the couples had concerns that were not associated directly with the procedure or personnel. Because IVF is not currently covered by health-care insurance plans, couples financed the treatment themselves. The resultant financial drain resulted in feelings of anger. Another outside influence was the long travel time for those who made their daily trips to the hospital from outlying communities. Some negative aspects of the IVF experience were unique to the husbands. Many husbands expressed feelings of fear for their wives’ safety during the laparoscopy, guilt that their wives were the ones who bore all the pain and discomfort, and helplessness in the face of their wives’ grief when a treatment was unsuccessful. Be-
349
cause their roles in the IVF procedure are rather peripheral, husbands sometimes felt left out and uninvolved. Identified as the most difficult part of the experience, the waiting period after embryo transfer (about two weeks) was reported to cause anxiety about the outcome, uncertainty about what and how much activity was allowed, and feelings of helplessness. During this period, most women restricted their activities severely, with some women putting themselves on strict bed rest for two weeks. Another five couples identified the most difficult part as the arrival of the menstrual period, the sign that the treatment attempt had failed. In all cases this was a time of grieving. A s one woman commented, “It feels like a hole in your heart; the emptiness of the death of an imagined child.” Another common phenomenon was observed that seemed to exacerbate the situation. Couples invariably tried to explain an unsuccessful outcome in a way that was meaningful to them. Unfortunately, rather than focusing on the current technical problems with the procedure, their explanations tended to involve some kind of self-blame. This belief that the failure was somehow t h e couple’s fault only added to the pain and grief already being experienced. Couples were asked if this experience had reminded them of anything. The eight couples who compared the IVF experience to another experience that involved a loss cited the death of a close friend, the loss of a job, bankruptcy, and giving up an infant as a teenager as examples. In the majority- of cases, however, these couples had never faced a similar problem in their lives. They had been accustomed to achieving other life goals through hard work and perseverance and were frus-
350
trated that these qualities had not helped them in this case. The author had anticipated that these couples might feel isolated from others, and reluctant to share knowledge of their participation in the IVF program. The couples were selective about who they told and, in fact, three couples told no one. However, 26 couples received positive responses from friends, colleagues, or relatives. As with other technological advances, mass media transmission of information h a s been a major force in shaping public attitudes. However, fears of criticism from others were not unfounded as eight couples received negative responses from others. Couples were asked what aspects of their lives, if any, had been affected by undergoing IVF. The wives of the 12 couples who identified the wife’s life goals as being significantly affected by IVF spoke of feeling “in limbo” and that “life was on hold.” Many women had postponed or given up academic or career opportunities to devote themselves to the pursuit of pregnancy. In addition, because of the increasing demand for IVF, couples usually have to wait several months before they have the opportunity to try IVF again. While these responses reflect the lengthy process of infertility investigation and treatment in general as opposed to the IVF experience specifically, for women, the choice t o pursue treatment often compromises other life goals. The 23 couples who reported that the experience had a positive impact on their relationships cited improvement in their communication through the need to discuss openly what their relationship meant to them and what children meant to them. Wives commented specifically on the support they had received from their husbands, that the experience had brought
out previously unknown strengths and qualities. These couples reported that t h e joint effort involved, the discovery that they could lean on each other in hard times, and the realization that just the two of them were involved had brought them closer together. In the remaining couples (n = 5 ) , however, the experience served to heighten tensions already existent in t h e marriage. Wives’ mood swings (related to t h e medications), decreased sexual spontaneity, conflicts regarding readiness for children, and an inability to give support to each other when needed most all contributed to an overall decline in the quality of the relationship. Limitations
The following factors pose limitations on the results and conclusions of this study. First, the use of convenience sampling and the small sample size limit the generalizability of the findings beyond the study sample. These findings are dependent upon the perceptions of the couples undergoing IVF at the time of sample selection who agreed to participate in this study. In addition, the interview guide was not subjected to tests of reliability. ~
~~
NURSING IMPLICATIONS
The results of this study point to two primary needs of couples undergoing IVF: information and support. Nurses involved with these clients, especially those who are part of an IVF team, have important roles a s educators and counselors. Information
Generally speaking, these couples, many of whom a r e highly educated, a r e used to being in control of their lives and find the
September/October 1988 JOGNN
relative powerlessness of their situation extremely frustrating. The most common coping style seen in this study population was one of oigilant f o ~ u s i n g .Behaviors ’~ characteristic of this coping style include actively seeking information and a compulsive attention to the details of diagnostic procedures and treatment. For these individuals, security is based on the ability to explain what is happening to them and that sense of security is rooted in knowledge and full participation in care.
Couples undergoing IVF require comprehensive information and emotional support throughout the procedure.
I
As a result, nursing care for these clients should include provision of comprehensive anticipatory information and counseling about the procedure. Of particular importance is the need to prepare couples for the possibility of eggs not fertilizing, t o provide clear guidelines about activity restrictions after embryo transfer, and to reassure couples that a failed treatment attempt is usually not related to the woman’s activity. Because high anxiety levels interfere with learning, instructions and information may need to be repeated several times. Written materials about the procedure need to be geared to the common concerns of patients. Couples who have undergone IVF themselves could give valuable input into preparation of such materials. Of particular value in client teaching would be a videotape of a couple going through the IVF process. Nurses also need t o look for strategies to involve couples in evaluating their progress through the program. For those who wish
September/October 1988 JOCNN
to know, specific information related to potential drug side effects and the significance of laboratory test results should be given. Many couples in this study indicated that full knowledge of their progress throughout the procedure would have helped them to prepare for disappointment if t h e treatment failed. Support The results of this study suggest that the quality of human interaction throughout the program was one of the most powerful determinants affecting couples’ perceptions of the experience. While couples may be able to obtain support from a variety of sources and are perhaps not as isolated as was anticipated, the IVF team continues to have a major responsibility for personalizing the experience and providing professional grief counseling if the treatment attempt fails. Couples’ needs for support and counseling have implications for a n IVF nurse’s role description and for the numbers of patients that a nurse can effectively care for in an IVF program. In addition, other nursing staff who may be more peripherally involved with IVF couples need to be aware of t h e intense anxiety and subsequent grief reaction that most of these couples experience if a treatment attempt fails. In this study, the informal patient support network that developed was highly valued by couples. This support system should be encouraged and enhanced by the IVF nurse. For example, initial orientation to the IVF procedure might be done on a group basis, giving a particular cohort of couples a chance to meet one another. In addition, a core of volunteers could be developed, made up of couples who have previously undergone IVF. New patients could
be assigned a volunteer who would act as a support (if desired) throughout the procedure. This support would be particularly helpful for out-of-town participants. The use of lay volunteers could be modeled after the effective programs already developed for mastectomy and ostomy patients. In addition, group relaxation classes, particularly in the postembryo transfer period could be given at the hospital, or relaxation tapes could be offered for purchase. CONCLUSIONS
In vitro fertilization offers increasing numbers of infertile couples the chance to achieve a pregnancy. As a result, a descriptive study of 28 couples who had experienced at least one IVF procedure was conducted. Results indicated that couples undertaking this procedure need comprehensive information and a great deal of support. Nurses involved in IVF have important roles in teaching and counseling couples about the medical and emotional aspects of the procedure. ACKNOWLEDGMENTS T h e a u t h o r wishes t o thank C. Zouves, MD, and S. Brown of the Vancouver In Vitro Fertilization Program for their assistance with this study.
REFERENCES Hakim, E. 1982. Infertility: Diagnosis a n d clinical management. Family and Community Health. 5~61-72. Testart, J., J. Belaisch-Allart, and R. Frydman. 1986. Relationships between e m b r y o transfer a n d ovarian response and in vitro fertilization rates: Analysis of 186 human pregnancies. Fertil Steril. 45~237-43. Margalioth, E., D. Navot, N. Laufer, A. Lewin, R. Rabinowitz, and J. Schenker. 1986. Correlation between a zona-free hamster egg s p e r m penetration a s s a y a n d
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human in vitro fertilization. Fertil Steril. 45:665-70.
4. Rotmensch, S.. J. Dor, A. Furman, E. Rudak, S. Mashiach, and A. Amsterdam. 1986. Ultrastructural characterization of human granulosa cells in stimulated cycles: Correlation with oocyte fertilizability. Fertil Steril. 45:671-79. 5. Robertson, R., R. Picker, C. O'Neill, A. Ferrier, a n d D. Saunders. 1986. An experience of laparoscopic and transvesical oocyte retrieval in an in vitro fertilization program. Fertil Steril. 45~88-92. 6. Lejeune, B., M. Degueldre, M. Camus, M. Vekemans. L. Opsomer. and F. Leroy. 1986. In vitro fertilization and embryo transfer a s related to endogenous luteinizing hormone rise or human chorionic gonadotropin administration. Ferti1 Steril. 45:377 -83. 7. Link, P., and C. Darling. 1979. Couples undergoing treatment for in-
naacoq
fertility: Counselling services in an infertility clinic. Am J Obstet CyneCOI.135:177-80. 8. Menning, B. 1980. The emotional needs of infertile couples. Fertil Steril. 34:3 13- 19. 9. Link, P. and C. Darling. 1986. Couples undergoing treatment for infertility: Dimensions of life satisfaction. J Sex Marital Ther. 12:4650. 10. Lalos, A., 0. Lalos, L. J a c o b s o n , and B. von Schoultz. 1985. Psychological reactions t o t h e medical investigation and surgical treatment of infertility. Cynecol Obstet Invest. 20:209-17. 1 1 . Debrovner, C., a n d R. ShubinStein. 1976. Sexual problems associated with infertility. Medical Aspects
of
Human
Sexuality.
10:161-62. 12. O'Moore, A., R. O'Moore, R. Harris o n , G. Murphy, a n d M. Carruthers. 1983. Psychosomatic aspect of idiopathic infertility: Ef-
0
0
0
ybcuz++
fects of treatment with autogenic training. J Psychosom Res. 27:14551. 13. Strickland, 0. 1981. In vitro fertilization: Dilemma or opportunity. Adv Nurs Sci. 3:4 1-5 1 . 14. Lipowski, Z. 1970. Physical illness, the individual and the coping process. Psycho1 Med. 1:91-102.
Address for correspondence: Barbara Milne, RN, MScN, The University of British Columbia, T.F. 206-221 Wesbrook Mall, Vancouver, British Columbia, Canada V6T 2B5.
Barbara Milne is an assistant professor of nursing at the University of British Columbia School of Nursing in Vancouver, British Columbia, Canada. Ms. Milne is a member of the Canadian Nurses' Association and the Registered Nurses' Association of British Columbia.
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September/October 1988 JOCNN
In vitro fertilization (IVF) is one of the newest techniques for treatment of infertility. While the medical aspects of IVF have been extensively reported, little research has explored this procedure from the couple's point of view. In this descriptive study, 28 couples who had experienced at least one IVF procedure were interviewed. The results indicate that while IVF offers hope for infertile couples, the procedure, if unsuccessful, can be emotionally traumatic. In addition, the results suggest that comprehensive anticipatory information and emotional support are the primary needs of couples undergoing IVF.
Infertility, the failure t o conceive after 12 months of unprotected intercourse, affects 10-15% of North American couples.' While various forms of therapy are available for treatment of infertility, o n e of the newest and perhaps most controversial is t h e technique of in vitro fertilization (IVF). For a couple who has already undergone a multitude of tests and unsuccessful procedures, treatments, and, sometimes surgery, IVF may represent the couple's last chance of having their own child. However, the procedure requires a substantial investment of personal and monetary resources with only an approximate 15-30% chance of success.2
Accepted: December 1987
September/October 1988 JOCNN
RELATED LITERATURE
The number of couples in North America who are receiving IVF is rapidly increasing. A s a result, health professionals need to understand how IVF affects the lives of couples who undergo this treatment. While recent articles in the 1it e r a t ure have high 1ig h t e d t h e medical aspects of IVF,3-6 little research to date has explored this procedure from the couple's point of view. Understandably, couples enter an IVF program in an emotionally vulnerable state. According t o Link and Darling and Menning, who studied the emotional needs and dimensions of life satisfaction of infertile couples undergoing treatment, the stress of trying and failing to conceive for a number of
years has significant effects on individuals, relationships, and even careers7-' In addition, the process of diagnosing and treating infertility has a major impact on the lives of these couples.'o*" O'Moore et al. conclude that this impact is usually far greater when the treatment process is prolonged and unsuccessful,'2 which usually occurs with couples entering an IVF program. The problem of infertility alone often makes couples feel isolated from friends and family because of t h e strong social and cultural expectations to have children.* Couples undergoing IVF may feel particularly isolated. Strickland reports that because of the sensationalism and controversies surrounding IVF, couples might be reluctant to share knowledge of
347
their participation in this program As a rewith friends or re1ati~es.I~ sult, usual sources of comfort and support might be missing at a time when they were most needed, leaving these couples a t even more risk for emotional problems.
METHODS Purpose The purpose of this study was to answer the following questions: How is IVF experienced by couples who undergo the procedure? 0 What are the needs of these couples? 0
A descriptive approach, using
guided interview and participant observation techniques was chosen to answer these questions. Sample All study subjects were obtained from the IVF program at a large teaching hospital in Vancouver, British Columbia. Subjects were selected for the study if they were English-speaking, Vancouver residents, and had completed at least one treatment attempt of IVF. A treatment attempt corresponds with a one-month menstrual cycle.
Sample Twenty-eight couples were interviewed. The mean age of the husbands was 35 years and the mean age of t h e wives was 33 years. The majority were highly educated and of North American origin. These couples had been married an average of nine years and had tried to conceive for an average of six years. The majority had experienced more than one IVF attempt (n = 17), with five couples undergoing their fourth and last IVF cycles. Of the 28 couples, only two achieved pregnancy.
348
Procedure Couples were approached initially by one of the nurses on the IVF team and, if interested, were contacted by the author and invited to participate in the study. If the couple agreed, a joint interview with both partners was arranged at the couple’s home three weeks o r more after embryo transfer when the success or failure of the procedure would be known. Informed consent was obtained, and couples were identified by code number to maintain confidentiality.
RESULTS Couples were initially asked what words they would use to describe their overall experience. While a small number of couples (n = 6) used positive words such as “hopeful,” “exciting,” “interesting,” and “high tech,” the majority (n = 22) expressed strongly negative feelings. Words like “devastating,” “physically and emotionally draining,” and “heartbreaking” were used most frequently and demonstrate clearly the powerful impact of yet another failed attempt at pregnancy.
Instrument The interview guide consisted of six close-ended questions designed t o collect demographic data followed by a series of twelve open-ended questions about the IVF experience. These questions were designed to elicit the couples’ perceptions of both positive and negative aspects of the procedure, reactions of others, sources of social support, impact on lifestyle and marital relationship, and their ideas for improvement of the entire process. T h e interview guide was tested for content validity by medical and nursing experts who work with IVF patients and by two individuals known personally by the investigator who had undergone IVF. These latter two individuals also acted a s a pretest group for t h e interview guide.* The content of the interview guide was analyzed to identify persistent words, phrases, themes, and concepts central to the research topic. These were coded and developed into categories. These data were then tabulated and summarized using elementary descriptive statistics (averages and percentages). * A copy of the interview guide is available from the author. (See address for correspondence.)
While IVF offers some hope, the procedure may be physically and emotionally draining. Couples were also asked to identify the positive aspects of the 1VF experience. Four basic categories emerged: interactions with health personnel, hope, camaraderie with other patients, and outcome (for two couples). For those two couples for whom IVF was successful, the resulting pregnancy was seen as t h e most positive aspect of the program and well worth the overall investment. Couples were also asked to identify the negative aspects of the IVF experience. Again, four basic categories emerged: interactions with health personnel, characteristics of the procedure, outside influences, and husbands’ attitudes. Interactions with health personnel were cited as both the most positive and most negative aspects of the IVF experience by 15 of the 28 subjects. Nineteen of the couples mentioned some aspect of the IVF procedure itself as a negative aspect of the experience, and five
September/October 1988 JOG”
couples had concerns that were not associated directly with the procedure or personnel. In addition, couples were asked what part of the experience had been the most difficult for them. Fifteen couples identified t h e waiting period after the embryo transfer as t h e most difficult aspect of the experience. Couples were also asked if any previous experiences were similar to their IVF experiences. Eight couples compared the experience to a previous loss. Couples identified four major sources of support that emerged during the 1VF experience: each other (n = 19), relatives (n = 13), other IVF participants (n = 13), and friends (n = 9). Twenty-six couples received positive responses from their friends, colleagues, and relatives, and eight couples received negative responses. Three couples reported that they told no one of their experiences. When asked about effects of the IVF experience on their lives, 12 couples identified the wife’s life goals as being significantly affected by the IVF program. Twenty-three couples reported that the experience had a positive impact on their relationships, while five couples reported that the experience had a negative impact on their relationships. Despite the physical, emotional, and financial strains of IVF, 21 couples indicated that they intended to try again, and were already preparing for another attempt. Furthermore, of those couples who declined to undergo IVF again, four did so only because they had reached the trial limit (four treatment attempts) or the age limit. DISCUSSION
The most commonly cited positive aspect of the IVF experience
September/October 1988 JOCNN
I
I
I
The quality of couples’ relationshim with IVF team members i’s an important determinant in couples’ perception of the experience.
was couples’ interactions with certain members of the IVF team. Over one-half of the couples interviewed (n = 15) commented on the supportive and informative environment created by the IVF nurses, trust they felt in the staff, highly organized process that inspired confidence, and positive attitudes of everyone involved with the program. In addition to these general comments, the medical director of the program was singled out by 14 of the couples as being a major positive force in humanizing and personalizing the experience. With all other treatment options exhausted, the IVF program was seen as a ray of hope, however temporary, by 10 couples. Many couples indicated how privileged and excited they felt to have this opportunity. Despite knowledge of the low potential for success, couples felt that maybe they would be one of the lucky ones. The close friendship network that developed, primarily among the wives, was identified by nine couples as an unexpected bonus. Thirteen women sought out the opportunity to share their feelings and experiences with others going through the same procedure. This camaraderie was seen as a major source of support through a n emotionally difficult time. Paradoxically, t h e negative aspect most commonly cited (n = 15) involved interactions with health-care professionals associated with the IVF procedure. Those who had participated in the IVF program over several years
observed that the process had become increasingly impersonal and mechanical as the demand for the procedure and, hence, the demand on staff time had increased. This depersonalization was felt most keenly at the point when a treatment attempt failed and couples were actively grieving and in need of support. Other major concerns involved difficulties obtaining a satisfactory amount of information about procedures, laboratory test results, and drug side effects. Of the aspects of the IVF procedure that were identified as negative, the multiple injections and blood tests, ultrasounds, side effects of the drugs and anesthetic, time-consuming nature of the process, embarrassment associated with sperm donation, and the overwhelming number of instructions were all perceived as necessary but uncomfortable aspects of the treatment process. Those couples who had undergone more than o n e IVF experience commented that their anxieties about the procedure diminished decidedly with successive trials. As reported, five of the couples had concerns that were not associated directly with the procedure or personnel. Because IVF is not currently covered by health-care insurance plans, couples financed the treatment themselves. The resultant financial drain resulted in feelings of anger. Another outside influence was the long travel time for those who made their daily trips to the hospital from outlying communities. Some negative aspects of the IVF experience were unique to the husbands. Many husbands expressed feelings of fear for their wives’ safety during the laparoscopy, guilt that their wives were the ones who bore all the pain and discomfort, and helplessness in the face of their wives’ grief when a treatment was unsuccessful. Be-
349
cause their roles in the IVF procedure are rather peripheral, husbands sometimes felt left out and uninvolved. Identified as the most difficult part of the experience, the waiting period after embryo transfer (about two weeks) was reported to cause anxiety about the outcome, uncertainty about what and how much activity was allowed, and feelings of helplessness. During this period, most women restricted their activities severely, with some women putting themselves on strict bed rest for two weeks. Another five couples identified the most difficult part as the arrival of the menstrual period, the sign that the treatment attempt had failed. In all cases this was a time of grieving. A s one woman commented, “It feels like a hole in your heart; the emptiness of the death of an imagined child.” Another common phenomenon was observed that seemed to exacerbate the situation. Couples invariably tried to explain an unsuccessful outcome in a way that was meaningful to them. Unfortunately, rather than focusing on the current technical problems with the procedure, their explanations tended to involve some kind of self-blame. This belief that the failure was somehow t h e couple’s fault only added to the pain and grief already being experienced. Couples were asked if this experience had reminded them of anything. The eight couples who compared the IVF experience to another experience that involved a loss cited the death of a close friend, the loss of a job, bankruptcy, and giving up an infant as a teenager as examples. In the majority- of cases, however, these couples had never faced a similar problem in their lives. They had been accustomed to achieving other life goals through hard work and perseverance and were frus-
350
trated that these qualities had not helped them in this case. The author had anticipated that these couples might feel isolated from others, and reluctant to share knowledge of their participation in the IVF program. The couples were selective about who they told and, in fact, three couples told no one. However, 26 couples received positive responses from friends, colleagues, or relatives. As with other technological advances, mass media transmission of information h a s been a major force in shaping public attitudes. However, fears of criticism from others were not unfounded as eight couples received negative responses from others. Couples were asked what aspects of their lives, if any, had been affected by undergoing IVF. The wives of the 12 couples who identified the wife’s life goals as being significantly affected by IVF spoke of feeling “in limbo” and that “life was on hold.” Many women had postponed or given up academic or career opportunities to devote themselves to the pursuit of pregnancy. In addition, because of the increasing demand for IVF, couples usually have to wait several months before they have the opportunity to try IVF again. While these responses reflect the lengthy process of infertility investigation and treatment in general as opposed to the IVF experience specifically, for women, the choice t o pursue treatment often compromises other life goals. The 23 couples who reported that the experience had a positive impact on their relationships cited improvement in their communication through the need to discuss openly what their relationship meant to them and what children meant to them. Wives commented specifically on the support they had received from their husbands, that the experience had brought
out previously unknown strengths and qualities. These couples reported that t h e joint effort involved, the discovery that they could lean on each other in hard times, and the realization that just the two of them were involved had brought them closer together. In the remaining couples (n = 5 ) , however, the experience served to heighten tensions already existent in t h e marriage. Wives’ mood swings (related to t h e medications), decreased sexual spontaneity, conflicts regarding readiness for children, and an inability to give support to each other when needed most all contributed to an overall decline in the quality of the relationship. Limitations
The following factors pose limitations on the results and conclusions of this study. First, the use of convenience sampling and the small sample size limit the generalizability of the findings beyond the study sample. These findings are dependent upon the perceptions of the couples undergoing IVF at the time of sample selection who agreed to participate in this study. In addition, the interview guide was not subjected to tests of reliability. ~
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NURSING IMPLICATIONS
The results of this study point to two primary needs of couples undergoing IVF: information and support. Nurses involved with these clients, especially those who are part of an IVF team, have important roles a s educators and counselors. Information
Generally speaking, these couples, many of whom a r e highly educated, a r e used to being in control of their lives and find the
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relative powerlessness of their situation extremely frustrating. The most common coping style seen in this study population was one of oigilant f o ~ u s i n g .Behaviors ’~ characteristic of this coping style include actively seeking information and a compulsive attention to the details of diagnostic procedures and treatment. For these individuals, security is based on the ability to explain what is happening to them and that sense of security is rooted in knowledge and full participation in care.
Couples undergoing IVF require comprehensive information and emotional support throughout the procedure.
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As a result, nursing care for these clients should include provision of comprehensive anticipatory information and counseling about the procedure. Of particular importance is the need to prepare couples for the possibility of eggs not fertilizing, t o provide clear guidelines about activity restrictions after embryo transfer, and to reassure couples that a failed treatment attempt is usually not related to the woman’s activity. Because high anxiety levels interfere with learning, instructions and information may need to be repeated several times. Written materials about the procedure need to be geared to the common concerns of patients. Couples who have undergone IVF themselves could give valuable input into preparation of such materials. Of particular value in client teaching would be a videotape of a couple going through the IVF process. Nurses also need t o look for strategies to involve couples in evaluating their progress through the program. For those who wish
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to know, specific information related to potential drug side effects and the significance of laboratory test results should be given. Many couples in this study indicated that full knowledge of their progress throughout the procedure would have helped them to prepare for disappointment if t h e treatment failed. Support The results of this study suggest that the quality of human interaction throughout the program was one of the most powerful determinants affecting couples’ perceptions of the experience. While couples may be able to obtain support from a variety of sources and are perhaps not as isolated as was anticipated, the IVF team continues to have a major responsibility for personalizing the experience and providing professional grief counseling if the treatment attempt fails. Couples’ needs for support and counseling have implications for a n IVF nurse’s role description and for the numbers of patients that a nurse can effectively care for in an IVF program. In addition, other nursing staff who may be more peripherally involved with IVF couples need to be aware of t h e intense anxiety and subsequent grief reaction that most of these couples experience if a treatment attempt fails. In this study, the informal patient support network that developed was highly valued by couples. This support system should be encouraged and enhanced by the IVF nurse. For example, initial orientation to the IVF procedure might be done on a group basis, giving a particular cohort of couples a chance to meet one another. In addition, a core of volunteers could be developed, made up of couples who have previously undergone IVF. New patients could
be assigned a volunteer who would act as a support (if desired) throughout the procedure. This support would be particularly helpful for out-of-town participants. The use of lay volunteers could be modeled after the effective programs already developed for mastectomy and ostomy patients. In addition, group relaxation classes, particularly in the postembryo transfer period could be given at the hospital, or relaxation tapes could be offered for purchase. CONCLUSIONS
In vitro fertilization offers increasing numbers of infertile couples the chance to achieve a pregnancy. As a result, a descriptive study of 28 couples who had experienced at least one IVF procedure was conducted. Results indicated that couples undertaking this procedure need comprehensive information and a great deal of support. Nurses involved in IVF have important roles in teaching and counseling couples about the medical and emotional aspects of the procedure. ACKNOWLEDGMENTS T h e a u t h o r wishes t o thank C. Zouves, MD, and S. Brown of the Vancouver In Vitro Fertilization Program for their assistance with this study.
REFERENCES Hakim, E. 1982. Infertility: Diagnosis a n d clinical management. Family and Community Health. 5~61-72. Testart, J., J. Belaisch-Allart, and R. Frydman. 1986. Relationships between e m b r y o transfer a n d ovarian response and in vitro fertilization rates: Analysis of 186 human pregnancies. Fertil Steril. 45~237-43. Margalioth, E., D. Navot, N. Laufer, A. Lewin, R. Rabinowitz, and J. Schenker. 1986. Correlation between a zona-free hamster egg s p e r m penetration a s s a y a n d
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human in vitro fertilization. Fertil Steril. 45:665-70.
4. Rotmensch, S.. J. Dor, A. Furman, E. Rudak, S. Mashiach, and A. Amsterdam. 1986. Ultrastructural characterization of human granulosa cells in stimulated cycles: Correlation with oocyte fertilizability. Fertil Steril. 45:671-79. 5. Robertson, R., R. Picker, C. O'Neill, A. Ferrier, a n d D. Saunders. 1986. An experience of laparoscopic and transvesical oocyte retrieval in an in vitro fertilization program. Fertil Steril. 45~88-92. 6. Lejeune, B., M. Degueldre, M. Camus, M. Vekemans. L. Opsomer. and F. Leroy. 1986. In vitro fertilization and embryo transfer a s related to endogenous luteinizing hormone rise or human chorionic gonadotropin administration. Ferti1 Steril. 45:377 -83. 7. Link, P., and C. Darling. 1979. Couples undergoing treatment for in-
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fertility: Counselling services in an infertility clinic. Am J Obstet CyneCOI.135:177-80. 8. Menning, B. 1980. The emotional needs of infertile couples. Fertil Steril. 34:3 13- 19. 9. Link, P. and C. Darling. 1986. Couples undergoing treatment for infertility: Dimensions of life satisfaction. J Sex Marital Ther. 12:4650. 10. Lalos, A., 0. Lalos, L. J a c o b s o n , and B. von Schoultz. 1985. Psychological reactions t o t h e medical investigation and surgical treatment of infertility. Cynecol Obstet Invest. 20:209-17. 1 1 . Debrovner, C., a n d R. ShubinStein. 1976. Sexual problems associated with infertility. Medical Aspects
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10:161-62. 12. O'Moore, A., R. O'Moore, R. Harris o n , G. Murphy, a n d M. Carruthers. 1983. Psychosomatic aspect of idiopathic infertility: Ef-
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fects of treatment with autogenic training. J Psychosom Res. 27:14551. 13. Strickland, 0. 1981. In vitro fertilization: Dilemma or opportunity. Adv Nurs Sci. 3:4 1-5 1 . 14. Lipowski, Z. 1970. Physical illness, the individual and the coping process. Psycho1 Med. 1:91-102.
Address for correspondence: Barbara Milne, RN, MScN, The University of British Columbia, T.F. 206-221 Wesbrook Mall, Vancouver, British Columbia, Canada V6T 2B5.
Barbara Milne is an assistant professor of nursing at the University of British Columbia School of Nursing in Vancouver, British Columbia, Canada. Ms. Milne is a member of the Canadian Nurses' Association and the Registered Nurses' Association of British Columbia.
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