Human Fertility, 2015; 18(2): 121–127 © 2015 The British Fertility Society ISSN 1464-7273 print/ISSN 1742-8149 online DOI: 10.3109/14647273.2015.1006691

ORIGINAL ARTICLE

Impact of childlessness on life and attitudes towards continuation of medically assisted reproduction and/or adoption

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GITTE L. PETERSEN1, LENE T. BLENSTRUP2, BRENNAN D. PETERSON3, LISBETH B. KNUDSEN2 & LONE SCHMIDT1 1Department of Public Health, University of Copenhagen, Copenhagen, Denmark, 2Department of Sociology and Social Work, Aalborg University, Aalborg, Denmark, and 3Department of Psychology, Crean College of Health and Behavioral Sciences, Chapman University, Orange, CA, USA

Abstract Infertility and fertility treatment have the potential to impact and disrupt a couple’s overall life. In order to study the associations between the impact of childlessness on one’s life, and men and women’s attitudes towards fertility treatment continuation and/or adoption, we analysed data from a one-year follow-up questionnaire in a prospective, longitudinal cohort study of consecutive couples initiating fertility treatment in Denmark. The study comprised 302 couples with no children at baseline and no joint children at one-year follow-up. In total, 71.9% of women and 72.5% of men reported that they wished to continue fertility treatment, while 20.2% of women and 19.2% of men reported that they wished to pursue adoption. The attitudes of nearly 8 in 10 couples were congruent towards further fertility treatments, while nearly 7 in 10 couples were congruent in their attitudes to pursuing adoption. Significantly more men who reported a lower impact of childlessness on their daily life wished to continue fertility treatment, compared with those reporting that childlessness had a greater impact on their life. Among women, significantly more were undecided about whether or not to pursue adoption when reporting a greater impact of childlessness on social life, compared with those reporting a lower impact of their childlessness.

Keywords: Adoption, assisted reproductive technology, decision-making, family formation, infertility

Introduction

Most studies on fertility treatment experiences are concerned with factors associated with the discontinuation of treatment. Gameiro et al. (2012) showed in a recent review that some of the most commonly reported reasons for discontinuation included physical and psychological burden, relational and personal problems, and factors associated with organisational and clinical problems. Since infertility and childlessness have the potential to impact severely on overall life, the current study used couples who had undergone unsuccessful fertility treatments for one year and examined the association between the impact of childlessness on their lives, and men’s and women’s attitudes towards fertility treatment continuation and/or pursue of adoption in couples without any joint children. A second objective was to identify the levels of congruence in women’s and men’s attitudes towards continuing treatment and/or pursuing adoption at one-year follow-up after treatment initiation at a specialised fertility clinic.

Infertility is a reproductive disease that commonly impacts both members of a couple and leads to involuntary childlessness (Zegers-Hochschild et al., 2009). Since infertility and childlessness are associated with negative psychosocial consequences for individuals, couples, and their relationship with others, infertility and fertility treatment has the potential to impact dramatically and disrupt a couple’s overall life (Schmidt, 2006; Greil et al., 2010). For many infertile couples, the time between diagnosis, treatment and outcome can be extensive and, if medical treatments are unsuccessful, couples are left to decide if they want to continue treatments, stop treatment, pursue adoption or stay childfree (Greil, 1991; Daniluk, 2001; Verhaak et al., 2007). During this process, the couple experiencing infertility have to make several decisions regarding treatment continuation and/or other family building options.

Correspondence: Lone Schmidt, Associate Professor, MD, DMSci, PhD, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, PO Box 2099, DK-1014 Copenhagen K, Denmark. Tel: ⫹ 45 35 32 76 31. E-mail: [email protected] (Received 14 May 2014; revised 25 September 2014; accepted 8 October 2014)

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Materials and methods

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Study sample This study is based on a longitudinal, prospective Infertility Cohort, which is a part of the Copenhagen Multicentre Psychosocial Infertility (COMPI) Research Programme (Schmidt, 2006). New couples initiating any type of medically assisted reproduction (MAR) treatment at a specialised fertility clinic were consecutively recruited between 2000 and 2001 from four public hospital-based tertiary fertility clinics and one private clinic. During the study period, the Danish public health care system offered infertile, heterosexual couples with no joint child, up to three fully reimbursed in vitro fertilisation or intra-cytoplasmic sperm injection transfer cycles with fresh embryos. Further, couples were offered an unrestricted number of cycles with frozen embryo transfer and intrauterine insemination with the husband’s or donor’s semen until the woman reached the age of 40 years. All types of MAR were available with self-payment at private fertility clinics until the female age of 45 years. Between 1995 and 2002, 5600 children were adopted annually from overseas (mostly China, India, Columbia and Vietnam) and less than 30 children were adopted from Denmark each year (the Danish Board of Adoption, 2003). The costs related to adoption from a foreign country amounted to 50,000–110,000 DKR/ child (∼6,600–14,600 EUR) depending on whether or not the child was brought to Denmark. A reimbursement of 15,000 DKR/child (∼2,000 EUR) was provided by the government. Each partner in the study population completed a baseline questionnaire immediately before treatment initiation and a second follow-up questionnaire at one year. Response rates were 80.0% (2250/2812) at baseline and 87.7% (1934/2206) at one-year followup. From 1,027 couples who responded to the baseline questionnaire and did not have a joint child at the time, we excluded couples (i) who had become parents (n ⫽ 304) or were pregnant (n ⫽ 222) at one-year follow-up, (ii) who did not respond to any questions regarding whether or not they would like to continue medical fertility treatment or pursue adoption at the one-year follow-up (n ⫽ 176) and (iii) who at baseline were living together with their own or their partner’s children from previous relationship(s) (n ⫽ 23). Thus, this study was based on a cohort of 302 childless couples. Variables The measure of overall impact of childlessness on life was adapted from Miller et al. (1998). Participants responded to three items: ‘What consequence has the childlessness had for...’ (a) ‘your ability to carry on with daily life as usual?’, (b) ‘your ability to work?’ and (c) ‘your social life?’. The response key included (i) ‘a great deal’, (ii) ‘some’, (iii) ‘a little’ and (iv) ‘none at all’. Answers were dichotomised as ‘A great deal/some’ labelled

‘greater impact’ in the following text and ‘not at all/a little’ labelled ‘lower impact’. The two primary outcomes were measured at one-year follow-up: ‘I will like to…’ (a) ‘continue the treatment we are trying now’, (b) ‘try another kind of medical treatment’, (c) ‘adopt a Danish child’ and (d) ‘adopt a child from another country’. Response key: (i) ‘yes’, (ii) ‘maybe’, (iii) ‘no’ and (iv) ‘don’t know’. Attitudes towards continuation of medical fertility treatment were created from answers to (a) and (b). Participants responding (i) ‘yes’ to (a) and/or (b) were categorised as positive towards continuation of medical fertility treatment; responses (ii) ‘maybe’ and/or (iv) ‘don’t know’ were categorised as undecided; and ‘no’ was categorised as not wanting to continue medical fertility treatment. Attitudes towards pursuing adoption were created from answers to (c) and (d) in a similar way. Statistical analyses Descriptive statistics were expressed as numbers and percentages. Both exposure and outcome variables were analysed separately for female and male respondents. All comparisons were computed using chi-squared tests and we defined p values ⬍ 0.05 as statistically significant. All analyses were performed using SAS® version 9.2 for Windows. Ethical permission The study followed the Declaration of Helsinki, and the Scientific Ethical Committee of Copenhagen and Frederiksberg Municipalities had no objections (J.nr. KF 01-107/99). The study was approved by the Danish Data Protecting Agency (J.nr. 1999-1200-233).

Results Participants had been partners for an average of 8.5 years (standard deviation [SD]: 3.7) and had tried to achieve parenthood for an average of 5.3 years (SD: 2.3). Women were on average 33.0 years old (SD: 3.6) and men 35.5 years old (SD: 5.0). In total, 31% suffered from female infertility, 29% from male infertility, 12% were mixed female/male and 28% unexplained. The couples reported an average number of MAR treatment cycles during the previous year of 2.6 (SD: 1.2), and an average number of ART treatment cycles of 2.2 (SD 0.9). 60.3% of the participants had been in MAR treatment before inclusion in the study. Among the participants, 14.0% of the women and 26.7% of the men were from higher social class (including professionals, executives and medium-level white-collar employees), 60.8% of the women and 46.3% of the men were from medium social class (including low-level white-collar employees and skilled workers), 16.9% of the women and 23.3% of the men were from lower social class (including unskilled and semi-skilled workers and participants receiving social benefits), 7.6% of the women and Human Fertility

Continuation after unsuccessful treatment 123 3.7% of the men were students, and 0.7% women were housewives.

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Congruence in attitudes Table I shows women’s and men’s attitudes towards continuation of MAR treatment and pursuing adoption, respectively, after one year of unsuccessful treatment. Overall, 71.9% of the women and 72.5% of the men wanted to continue with MAR and a smaller proportion (20.2% of women and 19.2% of men) wanted to pursue adoption. The majority of couples were congruent in their attitudes towards MAR continuation and pursuing adoption. Overall, 78.8% of the couples were congruent regarding attitudes to continuing MAR with 63.6% agreeing on wanting to continue MAR, 9.9% being undecided and 5.3% not wanting to continue MAR. Similarly, overall 68.6% were congruent regarding attitudes towards pursuing adoption with 10.6% in favour of continuing with adoption, 41.1% being undecided and 16.9% against pursuing adoption. Attitudes to continuation of MAR and pursuing adoption Table II shows attitudes towards continuation of MAR and pursuing adoption for women and men, respectively, after one year of unsuccessful treatment. Overall, the same patterns were seen among women and men. The largest proportion of women and men were positive towards continuing MAR and were undecided whether to adopt a child (41.1% vs. 44.0%, respectively). The smallest proportion of women was among those who were negative towards both continuing MAR and pursuing adoption (1.7%). Among men, an equal share; 2.3% were negative towards continuing MAR and pursuing adoption, and negative towards continuing MAR and undecided regarding adoption. Overall, 11.6% of the women and 12.3% of the men wished to continue with MAR and pursue adoption.

Consequences for life Overall, a larger proportion of women compared with men reported a greater impact of childlessness for their ability to carry on with daily life as usual, their ability to work and their social life (Figures 1 and 2). Figure 1 shows the association between reported consequences of childlessness for life and attitudes towards continuation of MAR treatment for women and men, respectively. Compared with men who reported a greater impact on daily life, a larger proportion of those men reporting lower impact were positive towards MAR treatment continuation (76.7% compared with 61.5%) and smaller proportions were undecided or negative (p ⬍ 0.05). No statistically significant difference was found among the women. Figure 2 shows the association between reported consequences of childlessness for life, and attitudes towards pursuing adoption, for women and men, respectively. Women reporting a lower impact of childlessness for their ability to carry on with daily life were more often negative (32.0%) and less often undecided (47.9%) regarding adoption compared with those women reporting a greater impact for daily life (18.3% and 61.1% being negative and undecided, respectively) (p ⬍ 0.05). Women reporting greater impact of childlessness for social life were more often undecided (64.6%) about pursuing adoption and less often negative or positive compared with women reporting lower impact of childlessness for their social life (47.1% undecided) (p ⬍ 0.05). According to the reported impact of childlessness for life, no statistically significant differences in attitudes towards pursuing adoption were seen among men. Compared with women, a larger proportion of men reporting greater impact of childlessness for their ability to work were positive towards pursuing adoption of a child (30.3% of men compared with 15.6% of women). Amongst those who reported greater impact of childlessness on their personal lives, work lives and social lives, a higher proportion of women were not willing to adopt when compared with men (see Figure 2).

Table I. Levels of congruence in women’s and men’s attitudes towards continuation of medical fertility treatment and pursuing adoption, respectively, after one year of unsuccessful treatment at a specialised fertility clinic in Denmark. Want to continue medical fertility treatment Men Yes Women

Yes Undecided No

217 58 27

71.9% 19.2% 8.9%

219 192 21 6

72.5% 63.6% 7.0% 2.0%

Undecided 56 21 30 5

18.5% 7.0% 9.9% 1.7%

No 27 4 7 16

8.9% 1.3% 2.3% 5.3%

Want to pursue adoption Men Yes Women

Yes Undecided No

© 2015 The British Fertility Society

61 163 78

20.2% 54.0% 25.8%

58 32 24 2

19.2% 10.6% 8.0% 0.7%

Undecided 177 28 124 25

58.6% 9.3% 41.1% 8.3%

No 67 1 15 51

22.2% 0.3% 5.0% 16.9%

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G. L. Petersen et al. Table II. Attitudes towards continuation of medical fertility treatment versus pursuing adoption for women and men, respectively, after one year of unsuccessful fertility treatment at a specialised fertility clinic in Denmark. Women Want to pursue adoption Yes Want to continue with Yes medical fertility Undecided treatment No

217 58 27

61 35 11 15

71.9% 19.2% 8.9%

Undecided

20.2% 11.6% 3.6% 5.0%

163 124 32 7

54.0% 41.1% 10.6% 2.3%

No 78 58 15 5

25.8% 19.2% 5.0% 1.7%

Men Want to pursue adoption

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Yes Want to continue with Yes medical fertility Undecided treatment No

219 56 27

72.5% 18.5% 8.9%

Discussion The main findings of this study are that the majority of childless couples wanted to continue MAR treatment and a smaller proportion wished to adopt a child after one year of unsuccessful MAR treatment. Statistically significant differences were observed among men reporting greater impact of childlessness on daily life compared with those reporting lower impact and to those who reported more favourable attitudes towards continuing MAR treatment. Among women, reported impact of childlessness regarding ability to carry on with daily life, and consequences for social life were significantly different according to reported attitudes towards pursuing adoption. This is one of the first cohort studies to investigate psychosocial factors associated with women’s and men’s attitudes towards continuing MAR treatment, and attitudes towards pursuing adoption among couples treated unsuccessfully for one year at a specialised fertility clinic. Previous studies have investigated predictors for the discontinuation of fertility treatment. A recent review, by Gameiro et al. (2012), of predictors for discontinuing fertility treatment showed that physical and psychological burdens of treatment, marital and personal problems, and decisions to postpone treatment are of importance. In the present study, we found the overall consequences for childlessness on life to be of importance for attitudes towards continuing fertility treatment. However, it is difficult to draw direct comparisons as our focus was on the burden of the childlessness, rather than the burden of fertility treatment. Couple congruence can be defined as agreement between partners with regard to decision-making and to the strength or meaning of a stressor. A general trend in the findings was for a high amount of congruence between partners in relation to their decisions to continue medical treatments or pursue adoption. Couple congruence has been studied as a key component in adjustment to dealing with a variety of medical and psychosocial issues. Specifically, couple congruence has been linked

58 37 8 13

19.2% 12.3% 2.7% 4.3%

Undecided 177 133 37 7

58.6% 44.0% 12.3% 2.3%

No 67 49 11 7

22.2% 16.2% 3.6% 2.3%

with increased marital satisfaction in couples experiencing infertility (Peterson et al., 2003), increased relationship satisfaction in cohabiting couples (Willoughby et al., 2012), and increased cohesion in couples coping with breast cancer (Watts et al., 2011). When examining couple’s attitudes towards adoption, approximately one-fifth wanted to pursue adoption in the future, while more than a half were undecided regarding pursuing adoption at one-year follow-up. According to Letherby (2010), adoption can be a challenge to one’s self-identity, and thus expectations about one’s relationship and future likely play a key role in decisionmaking. According to Thorn (2010), adoption is often a last resort since the majority of infertile couples initiate medical treatment without considering alternatives, hoping that the treatment will be successful (Letherby, 2010). The low percentage of participants indicating that they wished to pursue adoption after one year of medical fertility treatment may reflect that the majority of the participants still had the possibility of future MAR treatment cycles. The number of participants who were positive towards pursuing adoption is higher than the number of participants who end up seeking adoption, as a five-year follow-up of the cohort showed that 6% had adopted one or more children. The same study showed that 74.7% of the women had a delivery within the five-year follow-up of the cohort (Pinborg et al., 2009). This likely explains some of the discrepancy between the proportion of participants who had positive attitudes towards pursuing adoption and the proportion who ended up seeking adoption. An interesting gender difference was found in the associations for how men and women respond to psychosocial stressors and treatment continuation decisions. When men feel their lives are greatly impacted by a long-term, uncontrollable stressor such as infertility, they appear to be more willing to reduce the stress of childlessness by being more likely to discontinue fertility treatments. Women, on the other hand, did not demonstrate such a difference. For women, childlessness having a greater impact for their ability to carry on with Human Fertility

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Continuation after unsuccessful treatment 125

Figure 1. Associations between reported consequences of childlessness for ability to carry on with daily life as usual, for ability to work, and for social life by attitudes towards continuing medical fertility treatment among women and men, respectively. Results from one-year follow-up after unsuccessful fertility treatment at a specialised fertility clinic in Denmark.

daily and social life was associated with an increased likelihood that they would be undecided regarding adoption. While it has been noted above that women are less likely to want to stop treatments because their perceived chances of success are still high, the findings related to adoption possibly show that the one-year point is a time when women who experience a greater disruption to their daily lives and social lives begin to contemplate other alternatives – perhaps beginning to change their © 2015 The British Fertility Society

attitudes from ‘will not adopt’ to ‘undecided about adoption’. The current study also suggested that across each of the domains where couples reported greater impact of childlessness on their personal lives, work lives and social lives, a higher percentage of women were not willing to adopt compared with that of men. We currently know very little about factors influencing infertile couples’ treatment continuation and adoption decisions. International research has shown

G. L. Petersen et al.

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Figure 2. Associations between reported consequences of childlessness for ability to carry on with daily life as usual, for ability to work, and for social life and attitudes towards adoption among women and men, respectively. Results from one-year follow-up after unsuccessful fertility treatment at a specialised fertility clinic in Denmark.

that few patients report that they are well prepared to make decisions about treatment uptake, and few are given the opportunity to discuss the advantages and disadvantages of ending treatment (Gameiro et al., 2012). This indicates the need for further investigation of how counselling for childless people could be conducted in order to improve the possibility of their making well-informed choices regarding if, and how, to become parents. The findings further indicate that couples experiencing unsuccessful fertility treatment

for one year are to a large degree positive towards continuing treatment, while they are more often undecided whether to pursue adoption in order to establish a family. This highlights the importance of disseminating information about different possibilities of establishing a family when experiencing infertility. The strength of this study includes the cohort design, which takes account of both partners and generated a high response rate. In addition, the publicly financed treatment cycles offered to Danish citizens makes DenHuman Fertility

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Continuation after unsuccessful treatment 127 mark well suited for studies such as this, because the risk of selection bias caused by socioeconomic inequality is minimised. The study was limited by the use of a quantitative method, which revealed factors of importance regarding infertility patients’ decision-making, but did not allow for further details which could possibly explain the identified associations. Moreover, the sample size was relatively small because the majority of the participants achieved an ongoing pregnancy, or became parents during the one-year follow-up. Future quantitative studies would benefit from including a larger number of participants, enabling multivariate analyses which could take potential confounders into account. Our findings suggest that future research focussed on the consequences of involuntary childlessness and infertility for men’s and women’s overall lives can be beneficial in informing how treatment and adoption decisions are made. These factors do not necessarily affect decisionmaking equally among women and men since indicators of personal value, worth, dignity and control are important for the personal identity of individuals (Coyle, 1999). Increased knowledge of factors influencing couples’ decision-making and attitudes towards MAR treatment and adoption could lead to the development of more effective counselling strategies for fertility patients. Acknowledgements The Infertility Cohort is part of the COMPI Research Programme initiated by Dr. Lone Schmidt, University of Copenhagen, 2000. The Infertility Cohort is a collaboration between the public Fertility Clinics at Herlev University Hospital; The Juliane Marie Centre, Rigshospitalet, Copenhagen University Hospital; Odense University Hospital; and Regional Hospital in Horsens (former Brædstrup). The present study of the Infertility Cohort is part of the project on ‘Family histories and establishing of daily life after fertility treatment’, which has received support from the Danish Council for Independent Research | Social Sciences (j.nr. 09-068855). The project is conducted in co-operation between Aalborg University and University of Copenhagen. Further, the COMPI study has received support from the Danish Health Insurance Fund (J.nr. 11/097-97), the Else and Mogens Wedell-Wedellsborg’s Fund, the manager E. Danielsen and Wife’s Fund, the merchant L.F. Foght’s Fund, the Jacob Madsen and Wife Olga Madsen’s Fund, and the Engineer K.A. Rohde and Wife’s Fund.

Declaration of interests: The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.

© 2015 The British Fertility Society

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Infertility and fertility treatment have the potential to impact and disrupt a couple's overall life. In order to study the associations between the i...
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