The status of stigma among female infertility patients
The present study shows that infertile women generally have a sense of stigmatization, particularly for the factor of social withdrawal. These results are similar to the results of Donkor et al. and Hollos et al. [11, 17]. In 2015, Jansen et al. observed 432 infertile women seeking treatment in the United States through online forums and pointed out that social withdrawal is one of the mechanisms used by infertile women to cope with stigma [9]. According to the social culture and traditional concepts in China, family succession has become an ethical issue in the public's mind and a generally accepted fertility value [18]. Many female infertility patients themselves have a strong desire to conceive and are more sensitive to words such as "pregnancy" and "children." Most of their peers already have children, and they feel different from others. They feel upset when asked about their children or when they face comments from others. They feel "pathetic" in the eyes of others and are considered a "joke." To escape these inner thoughts and avoid embarrassing situations, they are unwilling to go to parties with friends who have children, participate in activities, or contact people, which might result in social withdrawal.
Factors affecting the stigma of female infertility patients
According to the one-way ANOVA, the affecting factors mainly include education level, monthly income, occupation, medical coverage, infertility causes and the duration of the infertility period. Regarding these factors, we have the following findings. First, women holding a Master’s degree or higher experienced less stigmatization. Donkor et al. also found that tertiary education and higher social status were mediating factors in reducing a woman's perceived stigma [11]. This may be because women with higher educational levels tend to hold relatively stable employment positions and incomes. Their greater access to knowledge and their ability to study, communicate and adjust psychologically may also help them acquire effective treatment measures, relieve themselves from traditional discrimination, and avoid any sense of stigmatization [18, 19].
Second, the employed female patients and patients with high income had a lower sense of stigma. This is probably because these patients tend to devote more time and energy to their careers, recognize ego value, and win respect from others. Thus, work can help distract their attention from infertility.
Third, patients with shorter durations or with medical healthcare insurance had a lower sense of stigmatization. Alhassan and colleagues also pointed out that a longer duration of infertility was positively associated with depression [19]. Due to potential pressure from the surrounding environment and public opinion, a considerable number of infertile women choose to conceal their condition and even refuse to seek medical treatment, which delays their recovery from the disease [8]. Because longer treatment periods or greater numbers of failed treatments cost more money, appropriate medical insurance can effectively alleviate the patients’ financial burdens, thus reducing the degree of stigma.
Fourth, patients with ovulation disorders have the lowest stigma levels, followed by those with tubal infertility. In vitro fertilization for patients with ovulation disorders and tubal infertility, i.e., through embryo transfer, usually has a higher success rate according to data from our reproductive center. In contrast, endometrial and unexplained infertility are more difficult to treat, which explains their higher degree of stigma.
Advice on clinical care of infertile women
Few studies have been formally conducted on interventions related to stigma among infertile women, but the following approaches have been recommended in the literature [20]. The first approach is professional psychological consultation. Regular consultations can cover medicine as well as daily life, job hunting and other related topics. The consultants must have good insight into the patients’ emotional and psychological changes, understand the patients’ thinking, analyze the causes of stigma, and offer patients with proper psychological guidance and cognitive intervention. During consultation, nurses should play a pivotal role in addressing the stigma of infertility [16]. Both one-on-one and group consultations should be performed because the latter can motivate patient-patient communication and mutual support [20].
The second approach is social support in the community. An important reason for stigma is rejection and discrimination from the outside world and even from relatives and friends. Establishment of a "care-support" education club in the community is recommended [18]. On the one hand, the population can be educated in the club with knowledge of social care, through which the public’s stereotypes can be corrected, and a more tolerant and positive social environment can be created for patients [18]. On the other hand, family members and relatives should be educated to provide patients with more support and care to prevent patients from feeling alienated. This will undoubtedly help alleviate the patients’ stress and improve their self-confidence and self-esteem.
Third, better public medical healthcare should be implemented. The costs of infertility treatment are high because infertility has not yet been covered by medical insurance in most regions of China. Since economic factors are tightly associated with stigma, the establishment of targeted medical insurance plans or expense reimbursement can help patients accept more active interventions, therefore relieving a great burden on patients and their families.
Limitations
One limitation of the present study is that we only collected data from women who ‘experienced’ stigma, not from others ‘against’ them, which may have caused deviations.
Second, this study did not include stigma against infertile men. The causes of infertility from men and women are roughly half-and-half [21]. In Chinese culture, male factor infertility usually suffers more stigma. Accordingly, infertile men tend to hide the truth, and men who do not know whether they are infertile are not willing to accept physical examination. Thus, infertility tends to be attributed to women by society, regardless of whether women accept it. A lack of investigation of infertile men will aggravate society’s misunderstanding of women with infertility and women’s own suspicion of themselves. This is not good for improving the stigma level of women with infertility.