Burnout among Women with Infertility

I got the inspiration to study the concept of burnout and infertility while I was waiting for a glass of juice that I ordered near a fertility treatment center. I overheard a couple’s conversation as to how they were feeling so emotionally exhausted and tired after repeated failure of fertility treatment. They were also discussing as to how the treatment was expensive but they wanted to have a child of their own! I thought there are multiple perspectives hidden here to look at it as a problem. Problems also can be looked from multiple perspectives. Is it a problem associated with the mindset of the people that they are not willing to adopt a child but ready to invest in expensive treatments for a child of their own! Should I think about it as a problem that infertility treatment procedures and treatments are not affordable for all and the government should take measures to address the issues related to it! The list of multidimensional perspectives can go on but I choose to pick up the dimension of burnout to study. Burnout according to World Health Organization (June 2019) burnout is defined as “syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed,” The three symptoms included in the list are:

· feelings of energy depletion or exhaustion

· increased mental distance from one’s job or feelings negative towards one’s career

· reduced professional productivity

WHO also states that Burn-out refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life!

These symptoms sounds very similar to other mood disorders and anxiety disorders. Although, burnout is associated with only workplace, I wanted to explore can it also be experienced when one is undergoing treatment for infertility. As our overall mood is affected by how we feel about and experience something so important to one. For my study, it was having a child of their own! The demarcation is clear but exploring a phenomenon was no harm I thought.

My justification and research proposal as to why burnout and infertility can go hand in hand because, the treatment process is continuous. In India, the society and culture values having own children after marriage. And once diagnosed, infertility stays with the individual until treated successfully. I choose to study burnout among women as they are mostly the visible layer of the society who are cursed for being infertile and has to undergo various societal torture. The dread of infertility stays with the women every moment and till the day comes where it is treated, it will always be behind one’s back. The stress is immense for those with infertility. So, the idea was to explore, can the symptoms of burnout be experienced by women with infertility.

As I was doing my secondary research and continuous review of literature, I tried to understand the various models of burnout and thought of ways how burnout can occur at different stages of infertility treatment. Depression, anxiety, lethargy falls under the most commonly associated mental health disorders with infertility. It is difficult to distinguish between burnout and stress. If the feeling is short-lived or tied to a specific project, like completing rounds of oral medication of infertility treatment, then it is stress. On the other hand, if one never feels like facing the doctors, nurses, family members and friends, or feels like their treatment has become impossible, it is likely that burnout is looming.

Burnout is a gradual process which increases over time. It does not process from one day to the next. It can progress gradually if not addressed. The physical signs are like feeling tired and drained out most of the time, lower immunity, feeling sick more often, frequent headaches, back pain, muscle aches,, changes in appetite or sleep. Emotional signs of burnout include emotional exhaustion, detachment or depersonalization from the treatment process, family members and daily work, sense of failure and self-doubt, feeling helpless, trapped and defeated; loss of motivation, increased cynicism, decreased sense of achievement in terms of fulfilling ones roles and obligations. Behavioral signs can be like withdrawing from responsibilities, isolation from others, procrastination, using food, drugs, alcohol to cope, taking out frustration on others, skipping treatment appointments and other social and personal commitments events or increased tardiness.

I then made the research plan- deciding the target population age group, inclusion and exclusion criteria, methodology, mode of collection of data, analysis method. I decided to go forward with qualitative research as this is a sensitive research area and I wanted to get deep understanding of burnout among women with infertility. So, I developed a semi- structured questionnaire and an expert validation was done to achieve standardization. Review of literature was continuously done to achieve up to date and holistic understanding of the concepts. While conducting the ROL, in 27 May, 2019 the World Health Organization published the updated version of the concept of burnout and that it is not a disorder but this phenomenon was serious enough to cause trouble to one’s mental health. It was included it in the ICD-11.

I then designed the content for the consent form. After the consent form was ready, I ensured to go through the ethical guidelines of research before I start conducting my research at a full scale. I then shortlisted the list of fertility clinic and centers. As permission to talk to patients undergoing treatment had to be seeked, I went to the gynecologists and the HR of the various hospitals to facilitate the interview. This was actually a challenge as a number of hospitals refused to approve permission due to patient and doctor confidentiality. One hospital and a medical college was approved. The doctors and the hospitals valued research and were interested in understanding how burnout could be cured. The doctors asked prior permission from patients if they were interested in sharing their stories regarding their diagnosis and treatment process.

After the completion of the permission approval process, I set up interviews. The interviews were completed in a months’ time and further analysis was done. Thematic analysis was used for the analysis

A sneak peak in to the research and the findings of it:

Research question

Understand the experience of burnout among women with infertility.

Paradigms

In the study phenomenological paradigm is used. It means understanding the problem though the subjective experiences of the subjects.

Material

Semi structured interviews were conducted in a quite and comfortable hospital environment.

Participants

Participant characteristics

A total of 6 women between the age of 20 to 35 years, with diagnosis of infertility and undergoing an artificial reproductive treatment for the same, voluntarily participated in the study. The participants belonged to various religious backgrounds (Hinduism, Islam and Christianity) and spoke a diverse range of languages including Kannada, Assamese and Hindi. The participants were approached at various private infertility clinics and ART centres in Bangalore urban area. Informed consent was obtained from all participants and they were informed about the confidentiality and privacy of the responses they would provide and encouraged to respond as honestly as possible.

Sampling procedure

Sample was selected through purposive sampling method. The inclusion and exclusion criteria were established prior to approaching the participants. The inclusion criteria specified that the sample should comprise of those diagnosed with infertility (primary or secondary infertility) and have been undergoing treatment via artificial reproductive techniques. The individual is a resident of Bangalore urban area. The exclusion criteria decided was a history of major psychiatric or psychological disorder (personality disorders, schizophrenia or mood disorder spectrum etc.).

Materials

Semi Structured Interview Questionnaire

Procedure

Thematic analysis will be used. It will help researcher to move from abroad reading of the data towards discovering and framing specific research question. It will distil data and determine themes. Data is gathered from observational data, questionnaire statements, audio recording and transcripts. The Data will be then coded in a code book and then transformed into clear and concise form. It will be reviewed by two researchers. Consistency and validation will be ensured. The code will give themes. The themes and sub themes how to be identified giving the patterns. The frequency of occurrence, occurrence only when specific factors are present, the time, the day, week is to be noted down. Hence the theme will really be defined. Finally the names of each theme are decided and the description is written along. Quotations from the verbatim also taken to convey the meaning to the reader clearly.

Study design

Qualitative research design having a exploratory study employing thematic analysis for data analysis.

Data analysis

The data was analyzed by using codes and deriving themes and sub themes. It was then analyzed to explore burnout in women with infertility.

Ethics

· Institutional approval was obtained prior to approaching the sample for the research study.

· Informed consent was obtained from all participants prior to commencement of responding to the questionnaires. They were also informed of their right to withdraw from the study if they wished to do so at any given point of time along the duration of the study.

· Privacy and confidentiality of the participants was ensured. The data collected was coded before being subjected to analysis and group data was utilized to draw conclusions.

· It was ensured that the participants faced no physical or psychological harm as a result of their participation in the study.

· Debriefing the participants about the results post completion of the study was also ensured.

Findings and Discussion

The various themes observed are emotional exhaustion, social support, family support, physical exhaustion, solidarity between partners, attraction between partners and self care. All these factors or themes play an important role in determining burnout. A study done on burnout among infertile women in Hungary by Enikő Lakatos, Judit F Szigeti, Péter P Ujma, Réka Sexty, and Piroska Balog revealed that age, social and sexual concern, maternal relationship stress and financial stress were major causes of distress. The study included women with only primary infertility. The cause of distress is mostly amplified by cultural factors like fertility expectations. Also, the motivation of women to have children is validated by the social norms and expectations which make the news of infertility for the couple more badly. The study also revealed that older age was associated with higher level of depression in the infertile women. Studies have been done that found similar themes in other working population and people with stress related and chronic medical illness. There are a very few studies where these themes have been explored in the area of infertility. These themes are scope of future trends in research related to infertility. The themes can be researched from a standalone perspective or combined

This study contributes to the future research perspective where burnout can be explored as the result of infertility. The various dimensions of burnout in infertility like emotional, physiological, somatic and psychological can also be researched independently. It will contribute to infertility counselling and designing intervention tools for women with infertility.

Due to various obstacles like time restriction, difficulty in receiving consent from hospitals and patients, etc the research was done on a smaller scale. It is highly recommended that more research should be done and infertility may be addressed as a community problem and rehabilitation models should be developed for the growth, sustenance and well being of the individuals with infertility. It can also contribute to develop effective family planning modules and schemes. It will be helpful in policy formation for various medical and government projects. The results can be used as a reference and pilot study for working on bigger projects which can be generalized. Various variables that can be studied are number of years of diagnosis of infertility, wider age group of the women, and number of failures of ART, the satisfaction from doctors ‘treatment and its relation to burnout .

Along with these factors, the concept of burnout should be modified and cultural specificity should also be taken into consideration. India being a collectivist society, the rate of burnout experienced by women is higher. The various aspects of burnout can be explored in a more expansive and a holistic way. The results can be generalized to a greater population size. There are various consequences of burnout. It can impact the interpersonal relationships in a negative way like increase in divorce rates, separation, domestic violence etc. It is another area of research which needs to be focused.

Lastly, infertility and burnout are related and infertility can induced burnout among women undergoing treatment for the same.