This chapter introduces the concepts associated with involuntary childless

This chapter introduces the concepts associated with involuntary childless. Various socio-cultural norms world over, global and Indian statistical, prevalence of infertility, stratification of infertility, health care mechanisms available for addressal of infertility and reproductive health rights in the context of millennium development goals and sustainable development goals-2030 will be discussed in the chapter.
Incidence and Prevalence
Infertility is a world wide issue affecting spanning across all geographical locations, across all demographics and socioeconomic status. It has been said that about eight to ten percent of all couples within the reproductive age have sought medical treatment and testing at some point in their lives for a suspected infertility. Globally, about sixty to eighty million people are said to be suffering from infertility, of which between fifteen to twenty million are in India. The World Health Organization (WHO) defines infertility, as the failure to conceive and have a biological child over twelve months of cohabitation and active sexual life. This chance of conception reduces in an individual aged thirty five and above.
Epidemiological data from the WHO has identified that regions of Central Africa has the highest incidence of infertility and has been known to reach fifty percent as opposed to twenty percent in he Eastern Mediterranean region, and 11% in the developed economies.
There have been no specific studies conducted in India to know the incidence and prevalence of the condition. The limited available data is from the National Family Health surveys and Census, which measures the number of women without children, but dosen’t evaluate the causes of the same. Childlessness has been found to be 2.4% among all married women in the country.
In the other South Asian countries, statistics the same as India have been seen. (Bangladesh, four percent; Nepal, six percent; Pakistan, five percent; and Sri Lanka, four percent). Globally, also three to six percent of the population has been identified to have infertility. Middle East, three percent; Latin America: three percent; Europe: five percent; North America: six percent; Caribbean: six percent)
Reproductive Health
UNFPA, 1994, in their charter on Programme of Action of the International Conference on Population and Development, has cited that ‘Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes.’ This definition makes clear that the individuals have the right for seeking information, access to good health care services, right for safe family planning methods as granted to them by the law, right to seek appropriate health care services which ensures women to safely undergo pregnancy and childbirth and gives the couple every chance to have a healthy infant.
Based on these, it can be said that reproductive health care is an umbrella term used for explaining methods, techniques and services accessed by those in need for prevention on reproductive health care needs and also solving them. Sexual health also forms one of the important aspects of reproductive health.
1.3.1 Millennium Development Goals, Sustainable Development Goals (SDG-2030) and Reproductive Health
The World Health Report 2005: Make Every Mother and Child Count (WHO, 2005) has mentioned the importance of mental health for maternal, new born and child health. They have trained midwives and other based health workers for understanding and evaluating maternal depression, post partum psychosis, suicidal ideations and immediate first aid to manage such situations. The International Conference on Population and Development (ICPD) Programme of Action and the Beijing Platform for Action, has sought its member nations to take action for rectification of gender based violence and unsafe abortion, so that lives of young mothers can be helped better. In addition, the mental health aspects of reproductive health are critical to achieving Millennium Development Goal (MDG) 1 on poverty reduction, MDG 3 on gender equality, MDG 4 on child mortality reduction, MDG 5 on improving maternal health and MDG 6 on the fight against HIV and AIDS and other communicable diseases. Good reproductive health can be achieved when mental health and functionality can be achieved by an individual.
There is a difference between developed and underdeveloped nations in terms of access to care and reproductive health care services. World over, the aim of reproductive health has been to address economic, demographical variations, health status and health service factors that impact morbidity and mortality. Unsafe abortion, hemorrhage, childbirth and the period of pregnancy have been identified to be of highest risk. Even though such constraints exist, mental health is has not been taken as major determinant of health pregnancy.
1.3.1 Reproductive Health Rights
UNFPA, 1994 and Ravindran, 2001 have defined the concept of reproductive health rights. Reproductive rights comprise a constellation of rights, established by international human rights documents, and related to people’s ability to make decisions that affect their sexual and reproductive health (Ravindran, 2001). it considers conception and childbirth as basic rights of individuals just as a fundamental right. Power to decide freely, how many children they want, and to attain the highest standard and quality of sexual life they would like to have. It also ensures their right to make decisions in matters of reproductive health as free of discrimination, coercion and violence, as expressed in human rights documents (UNFPA, 1994).

Women have been portrayed as the weaker sex throughout and infertility has been seen as woman’s problem. A gender based perspective adds weight to this conceptualization. This does not rely on the biology of the individual, rather as a rights perspective. It expresses on how a woman’s biology can be a vulnerability.
Psychological wellness issues may create as an outcome of reproductive health issues. These incorporate absence of decision in regenerative choices, unintended pregnancy, hazardous fetus removal, sexually transmissible diseases including HIV, childlessness and pregnancy difficulties, for example, unsuccessful labor, stillbirth, untimely birth or fistula. Psychological wellness has a proportionate relationship with physical wellbeing. It is for the most part more difficult when physical health including nutrition is poor. Depression after labor is related with maternal physical ill-health is associated with abdominal wounds or perineal injuries and incontinence.
Ravindran, 2001, has portrayed in the work by the WHO on Women’s emotional wellness and mental health about the different Reproductive privileges of the female partner. The rights that are being depicted by her have its premise in the different audits of writing and the group from the WHO that has been working in the domain. Based on the findings of the team, she has proposed nine points which need to considered as Reproductive Rights of Women.
These are: –
the right to life;
rights to bodily integrity and security of the person (against sexual violence, assault, compelled sterilization or abortion, denial of family planning services);
the right to privacy (in relation to sexuality);
the right to the benefits of scientific progress (e.g. control of reproduction);
the right to seek, receive and impart information (informed choices);
the right to education (to allow full development of sexuality and the self);
the right to health (occupational, environmental);
the right to equality in marriage and divorce;
the right to non-discrimination (recognition of gender biases)
1.3.3 The Role of Mental Health in Reproduction and Women’s Mental Health
Mental health is an important aspect of reproductive health., even though has limited space and the attention given to this is negligibly small. The absence of consideration like other medical illness has led to significant contributions in incereasing global burden of illness and and disability.
Psychological well-being issues may create as a result from conception related medical issues . These incorporate absence of decision in conception choices, unintended pregnancy, risky fetus removal through unsafe abortions, sexually transmissible diseases including HIV and pregnancy complications like unsuccessful labor, stillbirth, premature birth or fistula. Positive mental health is firmly joined with physical well being. It is for the most part more awful when physical well being including nutritious status is poor. Melancholy and sadness after labor is related with maternal physical morbidity, including tireless unhealed stomach or perineal injuries and incontinence.

Neuro-psychiatric disorders top the list of incapacity among persons world over among common ten such condition’s. Depression is the commonest among such conditions. Affective disorders are the leading cause of or over one in 10 disability-adjusted life-years (DALYs) lost (Murray ; Lopez, 1996).One DALY is calculated as a year lost from healthy life. Depression is seen more commonly in women as compared to men. It has been identified by various studies and also by Murray ; Lopez, 1996, that unipolar depression as one of the major illness creating more DALY’s than any other condition in the context of childlessness. It has been estimated that men loose upto three DALY’s against women with loss of nine DALY’s ,Murray & Lopez, 1998. current statistics state that more than one fifty million people world wide experience depression each year.
There is a lack of awareness among women about their own health problems. They have been used to the idea of “normal” to have health issues and to not seek treatment until the condition deteriorates further. There is a social stigma attached to feeling emotional and vulnerable. This culture of silence is even more when there are mental health issues involved. Mental health problems create a sense of feeling abnormal in women with involuntary childlessness. Hence, it is quite difficult to quantify the impact of mental health on reproductive capacities cannot be truly ascertained.
1.3.3.1 Determinants Of Mental Health
The World Health Organization defines mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”. This can also be interpreted as, the lack of mental health problems also do not assure good mental health.
Individuals with involuntary childlessness have been known to have mild to moderate depression,anxiety and difficulties in coping with stressful situations. The “capability approach” by Amrtya Sen says that “the range of things which people value doing or being may vary from “elementary ones (such) as being adequately nourished and being free from avoidable disease to very complex activities or personal states, such as being able to take part in the life of the community and having self-respect”. This condition also needs to be seen from a capability based approach since, all individuals seeking treatment by their choice are seeking resorts within their limitations to absolve their insecurities and live a life of self-fulfilment.
There are five broad determinants of mental health which can be applied to identify and apply strategies to seek interventions for reduction in mental disorders and promote well-being of mental health in an person.
“The determinants are:
Life course : Prenatal, Pregnancy and perinatal periods, early childhood, adolescence, working and family building years, older ages all related also to gender;
Parents, families, and households: parenting behaviours/attitudes; material conditions (income, access to resources, food/nutrition, water, sanitation, housing, employment), employment conditions and unemployment, parental physical and mental health, pregnancy and maternal care, social support;
Community: neighbourhood trust and safety, community based participation, violence/crime, attributes of the natural and built environment, neighbourhood deprivation;
Local services: early years care and education provision, schools, youth/adolescent services, health care, social services, clean water and sanitation;
Country level factors: poverty reduction, inequality, discrimination, governance, human rights, armed conflict, national policies to promote access to education, employment, health care, housing and services proportionate to need, social protection policies that are universal and proportionate to need.”*
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* adapted from the WHO and Royal College of Psychiatrists document on Social Determinants of Mental Health, 2014 series.
1.3Transition in Human Fertility
Fertility transitions, ie. the childbearing and fecundity among populations has been seen to follow highly unpredictable statistics. Countries with developed economies in the past years has seen a transition to such levels below replacement level of one. A few Asian countries have also seen similar results, with levels of two. Many developing countries have seen sudden decline in fertility rates. This was debated and discussed by Malthus in “Essay on the Principle of Population”, (Malthus,1798)
Cleland & Wilson, 1987, in their article has said that there are many theories which try to explain why some countries have undergone significant fertility transitions. But there has been no single comprehensive theoretical framework which explains this. In this context, Mason 1997, developed her own theoretical framework which conveys ideas and is also interactional with the public using it. Ideational so that people are able to recognize changing perceptions towards induced fertility reductions and interactive, so that existant conditions and co-existant changes are also considered.

According to this model, a country’s fertility level is determined by three proximate factors: The perceptions among reproducing people of children’s probabilities of surviving, their perceptions of the costs and benefits associated with having children, and their perceptions of the costs of postnatal versus prenatal controls on family size and composition, with costs incorporating both social, psychological, and financial aspects.This model views each household as a single unit. Hence it is also open to accepting that men and women in the house may have different points of view about fertility and reproductive health. Mason, 2001 has said that power structures within households is based on the sex who also is also the powerful partner in fertility decisions.
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(Mason, 1997)*, model adapted from Mason, K. (1997). Explaining Fertility Transitions. Demography,34(4),443-454. Retrieved from HYPERLINK "http://www.jstor.org/stable/3038299." http://www.jstor.org/stable/3038299. This model was developed to understand interactions between different factors that lead to lower fertility rates and replacement levels.
1.3.1 The Case of South India*
The South India Fertility study is a baseline of trends and transitions about demographic and fertility transitions in the southern states of India. It is a geographical study about village level changes in child bearing capacities. It has been anticipated that future fertility will be based socioeconomic, socio-psychological, and cultural developments in societies. Hence, this study has a predictive nature about human fertility transitions in the southern states in comparison to the northern states. Better standards and easier access to education for women, being career oriented- at least do work in small scale industries in the villages, becoming independent- economically and emotionally and also having buying capacities to suit their needs has contributed to such an autonomy, Frejka and Calot 2001; Lesthaeghe 2001; McDonald 2000. This trend has been known as the second demographic transition. van de Kaa 1987, says that with this sense of autonomy , such transitions are accompanied by changes in attitudes and behaviors which define sexuality, contraception, marriage, divorce and in certain cases having children outside of wedlock.
Pathways of Help-Seeking
The methods of seeking treatment and medical help by affected men and women are known as pathways of help-seeking. Ravi, 2017 has identified four pathways of medical help seeking by affected women .
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*Guilmoto, C. Z., & Rajan, S. I. (2001). Spatial patterns of fertility transition in Indian districts. Population and development review, 27(4), 713-738. a study specifically undertaken to understand transitions in population in South India compared to rest of India.
The common types of treatment seeking patterns were identified to be :
Allopathic-Ayurveda-Allopathic-Ayurveda-Homoeopathy systems of medicine pathway
Allopathic-Ayurveda-Allopathic systems of medicine pathway
Allopathic-Ayurveda systems of medicine pathway
Allopathic-Homoeopathy systems of medicine pathway
These women had approached different systems of treatment for seeking resolution for their involuntary childlessness related difficulties. The Government of Kerala had introduced a new system especially to cater to women in need, named AARDRAM. It is an initiative to make government hospitals more people friendly and to improve the basic infrastructure of government hospitals.
Ravi,2017 has also identified certain pathways of treatment seeking which were not popular but nonetheless were sought by affected women. These were;
Allopathic-Siddha-Homoeopathy systems of medicine pathway
Allopathic-Herbal systems of medicine Medicine pathway
Allopathic-Allopathic systems of medicine hospital in neighbouring state pathway
Couples seek different pathways for seeking adequate help for conception. These are based on accessibility, affordability and requirement of treatment needs.
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The want for children and the heartbreak from an inability have children been a part of life since the beginning of mankind, chronicled throughout history by religious accounts, myths, legends, art, and literature. Whether driven by biological drive, social necessity, or psychological longing, the pursuit of a child or children has compelled men and women to seek a variety of remedies, sometimes even extreme measures. In fact, in all cultures involuntary childlessness is recognized as a crisis that has the potential to threaten the stability of individuals, relationships, and communities.
Every society has culturally approved solutions to infertility involving, either alone or together, alterations of social relationships (e.g., divorce or adoption), spiritual intercession (e.g., prayer or pilgrimage to spiritually powerful site), or medical interventions (e.g., taking of herbs or consultation with ‘medicine man’).While spiritual and medical remedies for involuntary childlessness are common and often used early on by involuntary childless couples, social solutions demanding the alteration of relationships have been shown to be the last alternative individuals or couples usually consider.
CHAPTER 2
REVIEW
OF LITERATURE
This chapter discusses the concepts which are important to understand the phenomenon of involuntary childlessness as an effect of infertility. The relationship between infertility and involuntary childlessness, psychological dimensions of involuntary childlessness and causes for these conditions are being addressed in the chapter in detail.

2.1 Involuntary Childlessness And Infertility
The extend and impact of involuntary childlessness is felt mostly on pronatalist cultures. India is a pronatal society, a type of social functioning that guarantees respect and social dignity by conception and childbearing. These types of societies also have negate childless couples in social and emotional manners. Even though this condition is not immediately life threatening, it creates a sense of negativity, loss of autonomy , functioning and mental health in the long term. The impact is seen across various domains of the individual.
The lack of uniform definitions about infertility has been one the main difficulties faced by researchers. (Schmidt & Munster, 1995; Kols & Nguyen, 1997). WHO 2002 explains infertilty as the trouble faced by an individual for achieving pregnancy by a person of having a fulfilled relationship for a period of two years without the utilization of contraceptives. There is an absence of a settled meaning of barrenness, other than the reasonable translation taken after by the WHO. Infertility can be said as a group of heterogeneous conditions contributing to one’s inability to have a child,Marchbanks et al’,1989.
Jejeebhoy ,1998 has pointed out two main points that makes it difficult to define infertility, 1) a time period to be used for establishing infertility and 2) how to categorize women who have had one live birth but have not been to subsequently conceive.
For instance, the WHO definition, drawn up by the Scientific Group on the Epidemiology of Infertility (WHO,1991) has utilized a multi-year reference period: if the couple has never imagined regardless of dwelling together and introduction to pregnancy (not utilizing contraception) for a time of two years; essential barrenness is likewise alluded to as essential sterility; Infertility can be auxiliary, if a couple is not able to conceive after a failed attempt, in spite of living together and presentation to pregnancy (without contraception, breastfeeding or baby blues amenorrhoea) for a time of two years; this is otherwise called secondary sterility.
Childlessness is defined as the proportion of couples who have not had a live birth by the time of interview, despite at least five years of cohabitation and exposure to pregnancy and in the absence of contraception, breastfeeding or postpartum amenorrhoea. Unlike a couple with primary infertility, a childless couple also includes those who have successfully conceived but have failed to deliver a live birth. Similarly, secondary sterility in these studies refers to couples having difficulty bearing a second or higher order birth, despite usually five years of exposure, as in the definition above. The five year reference period is typically used, but not necessarily, in demographic surveys.

2.2.Medical Management of Infertility
The Penguin Dictionary of Psychology characterizes "barrenness as the state of having no offspring, which is transitory or reversible" .I .In medical terminology; infertility is an inability in a woman to conceive or a man to induce conception. According to standard medical definitions, a woman will be diagnosed as infertile when the woman does not become pregnant after a year of healthy marriage without any contraception.

Lindsay,1994 has said that treatments for infertility has developed as to keep up a paradigmatic case of a therapeutic circumstance in which all through a lot of its history doctors were men, patients were ladies, and the focal point of medicinal treatment was on the sexual organs . Despite there being equal chances of men or women being infertile, throughout history though women have been constantly targeted for being unable to bear a child.
This is a circumstance that has turned out to be significantly more noticeable with the approach of helped advancements in medical treatments in which the female experiences disproportionately more treatments, paying little heed to the etiology of the infertility could completely be on the man.
This worldview did not drastically move in spite of the appearance of artificial reproductive technique (ART), which started with the introduction of Louise Brown in Great Britain in 1978. Her origination through in vitro treatment (IVF) was the result of the work of British doctors Patrick Steptoe and Robert Edwards which started the concept that human propagation did not active procreative participation of a man and woman, instead utilized a variety of helped regenerative advances, and could be encouraged by donated gametes, embryos , and surrogacy.
With regards to headway of helped conceptive strategies, the infertility specific spectrum has extended to address the psychosocial difficulties of helped assisted reproduction and includes assessment, support, treatment, education, research and consultation. The focus of scientific researchers and researches become more inclined towards finding methods of assisted reproduction.
Evidence-based researches became more popular with a shift from assessment and intervention of an individual to that of group based approach. Pscyho-social research helps to identify such themes which need to be addressed and clinical issues which need immediate assessment.
2.3 Causes of Infertility
Identifiable factors affecting female infertility include: hormonal or endocrine disturbances (menstrual or ovulatory disturbances), tubal factors (occlusions, pelvic adhesions and other tubal abnormalities), acquired non-tubal factors (cervical or uterine disturbances), sexual dysfunction and congenital abnormalities. Among women common causes for infertility were endocrine issues thirty five percent globally and thirty seven percent in Asia, tubal factors thirty two percent globally and in Asia. Along with this untreated reproductive tract infections like including pelvic inflammatory disease, sexually transmitted diseases, gonorrhoea and repeated abortions are also known to have caused infertility. Even though these are identifiable factors, no causes can could be identified among one third of female partners visiting the clinics.
Among males, the commonest cause of infertility was oligozoospermia (semen contains too few spermatozoa), due to infectious factors, congenital factors, endocrine disturbances, immunological factors and varicocele, or idiopathic infertility (abnormal semen analysis results without etiological factors identifiable from history or physical examination). globally fifty eight percent men seeking treatment for infertility had no identifiable cause and twenty five percent of men had abnormal semen analysis results on checking. Knowledge about men’s infertility is still limited and treatment results may prove to be unsuccessful more often.

Papreen et. al., 2000 conducted a study in Dhaka, Bangladesh among Muslim population in a slum area. The variables of the study were perceived causes of infertility, treatment-seeking for infertility and the consequences of childlessness. It was identified in the study that the leading causes were believed to be the influence of black magic and physiological deficits in women. Among men, psycho-sexual and physiological deficits in men.
2.4 Involuntary Childlessness a Life Crisis- Studies on Psychological Impact On Men And Women
Infertility is seen as a couple’s problem. A man or a woman maybe able to concevive with another partner. In studies by Stanton & Dunkel- Schetter, 1991 and Dunkel- Schetter and Lobel 1991 have found that infertility creates levels of distress, adjustment related issues , depression, anxiety and reduced self-esteem among women. Men and women both assume that transition to parenthood is an important part of adulthood and hence a lack of ths same is seen as a life crisis. Stanton & Dunkel- Schetter, 1991.
Fecundity or the ability to produce children has a positive social value. Procreation is socially desirable for religious and family reasons. Children ensure the continuation of the family lineage. In India, childless women are often victims of societal wrath through isolation , impact on a woman’s identity, stigma and threat to a woman’s gender identity. They are isolated from auspicious functions in societies and with set limitations in functions like naming ceremonies or those associated with child birth.
2.4.1 Impacts of Involuntary childlessness – Gender based Perspectives , Marital Quality
Lavania, 2006 in her study among couples with fertility in India has identified that childless is a syndrome of multiple origins and is the result from a condition which prohibits natural conception. It is not a disease in itself. The couple get confirmed to a cultural expectation to produce children and a failure to do this leads to psychosomatic disorders and general dysfunction.
loss of relationship, good health, status in society, self-esteem, self-confidence, security, fantasy and loss of something or someone of great symbolic value were seen commonly among couples. Impact on marital relationships, sexual identity , self-esteem and communication pattern changes were seen among such couples. Shapiro,1982.

Social questions like, “How’s” and “Why’s”`are often difficult for such couples to answer. Inability to have a child was seen a failure to perform a role function associated with a gender, resulting in couple stigmatization. Women are often at risk of familial displacement in such situations. Rosenfeld (1984) and Miall (1986).
Marital life has often been affected among such couples, Sharma (1999) found that rates of divorce were higher among such couples than with others. Van Keep and Smith (1975) found that such couples also prefer to be in the presence of others with children than being totally isolated.
In a systematic review of the available online databases was conducted by Peng et.al (2012) , literature search was undertaken using multiple databases (Medline, PsycInfo and Scopus) to identify and synthesize all relevant literature published from 1990 to 2011. it was found that :
Impact on marriage was found to be associated with female infertility than male,
Infertile males were more satisfied in their marriages than infertile female partners
Infertile women felt more insecure in marriages than males in the same situation
Treatment experiences varies between men and women
Socio-demographic profile of the individual is an important factor
Quality of marital life is directly related to age of the couple, sexual gratification, education levels and their perception of the infertility problem.
Perceived mutual support among the couple has better impact on their treatment outcomes,Laffont, 1994
The impact of a diagnosis was more eventful for women than men
Bovin, 1998, identified that infertile men were more hopeful of favourable treatment outcome.
Research and treatment should be carried out on the couple seeking treatment than on individuals. Seeing infertility to have an impact on the dyadic relationships.
The studies were most often focused on the medical aspects than psycho-social domains.
Papers reviewed were in English, hence relevant papers in other languages would have been missed.

The findings were from a clinical population, hence the complete understanding and the complexity of the condition may not be understood . multiple perspectives could not be identified.
2.5 Psycho-social Interventions for Infertility and Involuntary Childlessness
Psycho-therapeutic interventions for addressing concerns and requirements related to infertility related distress has been studied and have been found to be the need of the hour. There has been an increasing understanding about the needs and requirements for specific terms and skill sets for infertility specific distress and psycho-education for infertility and childlessness.
Psycho-social interventions need to be addressed from both a medical and psychological aspect rather than taking an individualistic route. A medical approach assumes that only when the individual or the couple suffers severe distress should they be referred for psychological attention. But it has been seen from a psychological perspective that it is more beneficial and helpful if counseling is provided, research evidence suggests that men and women experiencing infertility and involuntary childless have a favorable attitude towards psycho-social interventions.
Infertility needs to be approached as a couples issue than as for an individual’s alone. Counseling is highly recommended for both partners together, there are gender based differences between men and women and women are more likely to see a counselor. For the couple, it is helpful to explain that infertility is a couple’s issue and therefore it is highly recommended that both the partners attend atleast the initial counselling together and provide information about the psycho-social aspects of infertility. Addressing the counseling and psycho-therapeutic needs of a couple requires an in-depth knowledge regarding the possible difficulties and areas that needs that cause distress to the couple. Certain organizations and ethical bodies have developed a codes of practice and practitioner’s both medical and psycho-social are expected to adhere to the guidelines given . the codes of practice to be followed by infertility specific counselors are :
Knowledge about the psychology of infertility (typical and atypical responses to infertility and medical treatment bereavement, and crisis intervention)
impact on the individual on self-esteem, effects on marital quality (such as gender differences and the impact on a couple’s sexual relationship) and societal issues (such as the stigma and taboo associated with infertility)
Assistance and assessment to help the family in building alternatives (adoption, third party reproduction, living without children)
Individual and couple counseling
Medical treatment possibilities
Pregnancy and birth following ART
Alternative medicine relevant for infertility
Legal and ethical issues related to ART. Furthermore, they must have a minimum of clinical experience in infertility counseling and under-go regular supervision and continuing education.
Van Balen and Inhorn (1997) cite the difficulty in conducting researches on infertility have mainly been due to the these four points,
It was considered to be a medical problem and one that did not need further discourses of action
A taboo subject, difficult to engage persons to speak about it.
Seen predominantly as a woman’s issue , had taken a gender based perspective always, changing social beliefs about parenthood and womanhood.
Researches were focused more on assisted reproductive techniques than on psycho-social impacts on individuals.
WHO (World Health Organization) has acknowledged that one of the main hindrances in treating and identification is the lack of uniform access to quality of healthcare world-over to this condition. There are no uniform standards about who needs what-type of care. There has always been a lack of clarity regarding the poulation who is in need of psycho-social aid. Of all the treatment seekers, about twenty to twenty five percent of individuals seek counselling aid. This was commonly seen in the Western countries than in Asian cultures. On the basis of this, a few pointers to who might benefit from a psycho-social aid has been identified.
Individuals and couples with marital distress and issues.
Past psychiatric history or those vulnerable for a developing one
Those who are unable to decide about treatment continuation
Those with a family history of genetic comorbidities
Women who are pregnant with multiples
Loss of pregnancy experienced by them more than once
Recipients of donor gametes, either from male or female.

2.6.1 Grief and Bereavement
Chronic Infertility-Specific Grief Model
Involuntary childlessness creates a sense of loss and sets in motion a process of grief and bereavement . it is a complex phenomenon encompassing a couple’s health and physiological goals, self-confidence, self perception and definitions of success. Grieving a process to naturalize this emotional turmoil. The intensity of process is based directly on the their desire for parenthood.
Chronic infertility-specific grief model was developed by Unruh and McGrath when traditional grief theories were not able to address grief among such couples. They developed the concept of disenfranchised grief. This is defined by three points,
Sense of loss is socially unrecognizable. The loss or inability to conceive is a private emotion, one that is felt only by the couple. 2) the loss of a child from a miscarriage or inability to have a child is abstract. Another person, friend or family members may not be able to see it. 3) since physically there has been no loss, the griever is not seen to have suffered a loss and hence is not justified in grieving.
Disenfranchised grief is more complex than traditional grieving process since there are no physical attributes for them to grieve on, it is often the loss of a set of ideas , wishes and plans of parenthood.
2.6. 2 Individual Identity Theories
Involuntary childlessness was explained as a narcissistic wound which explains how an individual imbibes the affect effect, as explained in Sense Of Self Model by Olshansky. According to this model, infertility alters one’s sense of self by changing, creating or increasing the individual’s sense by inducing feelings of deficiency, hopelessness, helplessness and shameful feelings.
The individual’s self perception is completely changed and gets affected. Their sense of self, individual identity as male or female gets changed and affected. From a successful person, their identity to a one with flaws and lacks, all of the individual’s future endeveours will then be based on managing this one limitation.
Kikendall’s application of self-discrepancy theory, is another theory that describes identity formation, this theory says that infertility is a personal identity crisis. A woman is faced with a conflict of her ideal sense of self of being a mother to a woman with infertility, a woman who may never be able to become a mother.

2.6.3 Theories Of Help Seeking
There are various studies which explain about the pathways of help seeking by those who are unwell, who seeks the help and when they seek it. One of the main deciding factors in this is the role of cognition. Among infertile couples, two specific processes have been identified in how they seek help sequentially: cognitive appraisal (perception of a fertility problem) and medical help-seeking.

Anderson’s (1968) Behavior Model of Health Services Utilization postulates that medical help-seeking is a function of perceived and evaluated need, predisposing factors (such as age, gender, past health, socio-economic status, and health beliefs), and enabling factors (such as income, medical care availability, community resources). illness behaviour, social contexts in which such decisions are made and plans of treatment seeking has been used as the framework for studying illness behaviours, Pescosolido (1992) and Shaw (1999)
When there is a distinct ability to perform daily and occupational tasks, it is then that the individual seeks help. The degree of desire to have a child is one which has the ability to disrupt plans, in such contexts individuals seek help, Mechanic (1968).
How the individual perceives childlessness , as a problem or as an event needing a solution decides their how they approach it. One such model postulated is being explained This framework is the Pathways of help-seeking often adopted by the involuntarily childless couple to get medical aid and help.
Help Seeking – Perception Of Problem And Seeking Medical Aid*
The model comprises of four contributing factors that leads to the individuals cognitive appraisal of being infertile, which is the perceived problem, resulting behavioural outcome being medical help seeking.
The contributing factors to the cognitive appraisal of infertility are :
Symptom Salience – Symptom in current context is infertility. Indicators of infertility salience include whether the woman was actively trying to get pregnant and the strength of her intention to bear future children.
*Andersen, R. M. (1995). Revisiting the behavioral model and access to medical care: does it matter?. Journal of health and social behavior, 1-10.463557620 this paper explains the causal effect relationship between help seeking behaviours and problem perception.
Life Course Cues: life course cues are important triggers for appraising lack of conception as a fertility problem and for seeking help. The cues include age, parity, and marriage, which is directly related as a trigger for normative childbearing
Individual And Social Cues: Individual cues for perceiving and seeking help for fertility problems include the importance of motherhood as a life goal and religiosity. Help- seeking theories suggest that social cues should be an important determinant of perceiving a problem and seeking treatment. In the case of infertility, the most important of these social cues is likely to be partner’s desires.
Enabling and Pre-Disposing Factors: The research by,Carpentier ; White, 2000, shows that social network support predicts help-seeking, hence expressive social support is included as a general enabling factor. The factors that generally predispose one to treatment seeking will be taken as measures of education, general health, internal health locus of control, and ethical concerns about artificial reproductive technologies (ART).

This model is one the basis to identify if the cognitive appraisals and perceptions remain the same, perception of the infertility problem and medical help seeking among infertile men and women. The help seeking model postulates about the various interactions and the causal effect relation between the individual and the factorial relations namely , the symptom salience, life-course cues , individual and social cues and the enabling and predisposing factors which leads to the perception of a problem. From the point of view of this study, the factors would be studied in depth with the aid of individual interviews with infertile couple and individually. The cognitive appraisal of the situation would be studied as from the couple’s perception, and the individual perception of the problem, which in-turn leads to the medical help seeking for the rectification of the problem. The researcher would study the following aspects in among the infertile couple , and the individual – Help Seeking Behavior , Medical Help Seeking Behavior, Perception Of Infertility Problem , Trying ,Parity ,Value Of Motherhood ,Value Of Fatherhood, Religiosity, Family Income, Social Support, Internal Health Locus Of Control, Subjective Health Ethical Considerations and Education.
Divorce, polygamy, and extramarital affairs remain, as they have long been, social solutions to infertility, as do various forms of adoption and fostering. Examples of other social solutions include the continuing practice in some cultures of multiple wives in response to infertility (or lack of a son) or the custom in some cultures requiring a sibling (usually an eldest son) to provide one of his children to a younger, childless sibling.
Women’s bodies, especially in developing countries, are frequently the locus through which social, economic, and political power is exercised. Where the role or status of women is defined by their reproductive capacity, as when womanhood is defined by motherhood, infertility can have significant social repercussions including unstable marriages, domestic violence, stigmatization and in severe cases, ostracism. Infertile women in developing countries may suffer life-threatening physical or psychological violence when having children is a woman’s only chance to improve her status in her society or family. Individuals who are thought to be infertile are generally relegated to an inferior status, and stigmatized with many labels. Hence, childlessness has varied consequences through its effects on societies and on the lifestyle of individuals. Parenthood is personal for some women, whereas by some as a duty.
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A short analysis of the studies from the review cite that parenthood is one of the major transitions in adult life for both men and women. The stress of the non-fulfillment of a wish for a child has been associated with emotional related problems such as anger, depression, anxiety, marital problems, sexual dysfunction, and social isolation. Couples experience stigma, sense of loss, and diminished self-esteem in the setting of their infertility. Although infertility is primarily a medical condition, its diagnosis can greatly impact the emotional functioning of couples dealing with this problem. Infertility is often an unanticipated, stressful, and life changing event. Infertility and involuntary childlessness have been often referred to as a developmental crisis that can threaten a couple’s future goals, as the family does not progress from the married couple without children, as a developmental phase.