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The Transition to parenthood after infertility Plomp, Deborah Adele 2003

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THE TRANSITION TO PARENTHOOD AFTER INFERTILITY by DEBORAH ADELE PLOMP B.A., The University of British Columbia, 1992 Dip. Ed., The University of British Columbia, 1999 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in T H E FACULTY OF GRADUATE STUDIES (Department of Educational and Counselling Psychology, and Special Education) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September 2003 © Deborah Adelc Plump, 2003 Library Authorization In presenting this thesis in partial fulfillment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Name of Author (please prM) ' D a t e (dd/mm/yyyy) Title of Thesis: D e 9 r e e : JAA Year: ^QC^ Department of €o^U.Ului it"' 7-' (qmSe)linC] l^li U Ol CPU The University of British Columbia ~~~{ : , - / ' —H~ Vancouver, BC Canada c ] l ^ 'J:f^-0<GV t(j(JCfitlM 11 Abstract Relatively little is known about the experience of those who make the adjustment to parenthood after a history of infertility and within the available literature there exists numerous gaps and inconsistencies. In this qualitative study, in-depth interviews were used to explore the experience of four heterosexual married couples making the transition to first-time parenthood after prolonged infertility. The study sought to answer the question, "What is the experience for couples making the transition to parenthood after primary infertility?" A thematic analysis of these data, using Colaizzi's (1978) seven step structured analysis, generated five phenomenological themes. In no specific order, the five themes are as follows: (1) A sense of gratitude/being blessed (2) A sense of appreciation/not taking parenthood for granted (3) A sense of completion/new connection (4) A sense of readiness/purposefulness (5) A sense of parenthood as a positive, healing experience. Overall, the data reflected the transition to parenthood after primary infertility to be predominantly a positive experience with the pain of infertility put aside, at least until the couples began to think of expanding their family once again. i i i Table of Contents Abstract i i Table of Contents i i i Acknowledgments v INTRODUCTION 1 Statement of the Problem 1 Purpose of the Study 6 REVIEW OF THE LITERATURE 9 The Transition to Parenthood 9 Infertility 14 Transition to Parenthood after Infertility... IV M E T H O D O L O G Y 40 Research Design 40 Method Selection 40 Personal Assumptions and Bracketing 41 Research Procedure 44 Participants 44 Criteria 45 Recruitment 46 Data Collection 47 Data Analysis 50 Thematic Analysis 50 Limitations 52 FINDINGS 54 Introduction... 54 Couples' Bio-Synopses 54 Identified Themes 63 DISCUSSION 92 Comparison with the Literature 92 iv Implications for Future Research 104 Implications for Clinical Practice 106 References 110 Appendices 115 Appendix A: Recruitment Advertisement 115 Appendix B: Study Participant Consent Form 116 Appendix C: Orienting Statement 118 Appendix D: Sample Interview Questions 119 Appendix E: Referral Source Sheet 121 V Acknowledgments This document could not have been written without the support and encouragement of a number of people. I would like to thank my research supervisor, Dr. Judith Daniluk, for her continuous positive encouragement and promptness in responding to any question or concern that I had throughout the process. It was truly a valuable experience working with her. Thank you to my family for their willingness to pitch in and help free up time for me to work by caring for my daughter. A special thank you to my mother, Margaret Plomp, who made it her mission to "get me through it" and who was and continues to be dedicated to her granddaughter. Thank you to Emma, my little girl, who taught me first hand about the transition to parenthood and who, despite her young age, was incredibly patient with me. You are my joy and you inspire me everyday to work hard and do my best. And to my husband, Art Gold, whose unconditional love and support bolstered me whenever I felt discouraged. A l l of my accomplishments in life are a reflection of your love and partnership. 1 Chapter One I N T R O D U C T I O N Statement of the Problem A considerable amount of research has been conducted on the experience of infertility (e.g. Daniluk, 2001; Gerrity, 2001; Menning, 1982) and its impact on the individual, couple, and extended family (e.g. Eunpu, 1995; Gibson & Myers, 2000; Shapiro, 1982). Similarly, an interest in the transition to parenthood has resulted in numerous studies (e.g. Cowan & Cowan, 1992; Belsky & Rovine, 1990; Helms-Erikson, 2001). Although literature on both the transition to parenthood and infertility is plentiful, little is known about the transition to parenthood after infertility. Eighty-five percent of couples with reproductive intention wil l conceive within twelve months (Corson, 1999) beginning their journey towards parenthood. For the other 15% of couples however, the road to parenthood will not be easy. It is estimated that approximately 50% of those seeking treatment wil l successfully conceive (McShane, 1997). While the movement from a unit of two to that of three is considered to be a normative and expected transition (Miller & Sollie, 1980), new parenthood comes with a unique set of changes and challenges, challenges that may well be compounded by a history of fertility problems and treatment. Over the last half century, the transition to parenthood and its impact on the individual and the marriage has been studied extensively (e.g. Belsky & Rovine, 1990; Cowan & Cowan, 1992; LeMasters, 1957). Numerous researchers have concluded that new parenthood entails a significant lifestyle adjustment (e.g. Cowan & Cowan, 1995; Levy-Schiff, 1994; Shapiro, Gottman, & Carrere, 2000). Common experiences of new 2 parents include chronic tiredness, increased housework, decreased marital intimacy, decreased time for self, economic pressure, change in work patterns, and a curtailment of social contacts (e.g. Miller & Sollie, 1980). Changes in marital roles, interactions, and quality also appear to be common (MacDermid, Huston, & McHale, 1990). Much of the available literature has focused on the apparent risks of new ' parenthood, such as increased marital conflict (Knauth, 2001), decreased marital satisfaction (MacDermid et al., 1990), and an overall negative pattern of marital change (Cowan, Cowan, Heming, Garrett, Coysh, Curtis-Boles, & Boles, 1985). Recent publications have concentrated on determining potential risk factors to marital well-being such as the timing of parenthood and the division of housework (Helms-Erikson, 2001), and identifying factors that might buffer against decline in marital satisfaction (Shapiro et al., 2000). While few studies have focused on the potential benefits of new parenthood, researchers have recognized that some couples will make the transition to parenthood with less difficulty (e.g. Levy-Schiff, 1994). Such couples include those whose background, sex-role attitudes, and beliefs are congruent with the division of household labour (Helms-Erickson; MacDermid et al.) and those who have greater paternal involvement with the baby (Levy-Schiff). Despite the changes and challenges of new parenthood, the creation of a child within North American culture is considered to be one of the most important and significant life accomplishments (Lee, 1996). Most couples believe that they have control over their fertility and when the time comes to start a family, they will become pregnant (Daniluk, 1998). Consequently, for couples unable to produce a child, the diagnosis of infertility is almost always unexpected (Leiblum & Greenfeld, 1997) and is often met with an overwhelming sense of disbelief (e.g. Daniluk, 1991; Shapiro, 1982). The process of coping with infertility is complex (Gibson & Myers, 2000). It has been referred to as a life challenge (Gibson & Myers) and a developmental crisis (Eunpu, 1995) with the potential to touch every aspect of a couple's life together. The treatment of infertility is often a long process, averaging five to seven years, which, as suggested in the substantial body of infertility literature, can produce considerable stress and have multiple psychosocial consequences (e.g. Domar, 1997; Eunpu, 1995; Gerrity, 2001). Potential negative effects include medical discomfort and invasiveness, diminished self-esteem, changes in the marital and sexual relationship, career interference, financial strain, and social isolation (e.g. Daniluk, 2001; Domar, 1997; Eunpu, 1995; Gibson & Myers, 2000; Leiblum, 1997). It appears that infertility can significantly challenge a couple's physical and psychological well-being. Infertility is not an uncommon diagnosis. The inability to procreate after a year or more of unprotected regular intercourse affects approximately 1 in 6 couples of reproductive age (Leiblum, 1997). These rates appear to be rising due to a variety of factors including delaying marriage and postponing parenthood (Corson, 1999; Eunpu, 1995; Menning, 1982). Of those who pursue medical fertility treatment, it is estimated that 40% to 60% will successfully conceive (Menning, 1982; McShane 1997). Given these statistics, it appears that an appreciable number of individuals will face the formidable challenges of making the transition to parenthood after experiencing the prolonged stresses of infertility. 4 Surprisingly, the potential impact of infertility on the transition to parenthood has received relatively little attention in the parenthood transition literature. What little interest there has been on the experience of parenting after infertility seems to have stemmed from anecdotal evidence described primarily in the works of Garner (1985), Bernstein (1990) and Glazer (1990). These authors suggest that parenting after infertility may involve challenges above and beyond those experienced by other new parents. The negative aspects of new parenting such as fatigue and decreased marital intimacy may be especially difficult for these parents to acknowledge given the challenges they faced in their efforts to become parents. Distress over their parental ambivalence may result from an idealization of parenthood (Garner, 1985) and a faulty belief that they should not be anything but grateful for their child (Bernstein, 1990). Based on both personal and professional experience, Glazer (1990) maintains that the experience of infertility does not necessarily vanish with the arrival of a child but may remain with people throughout the entire lifecycle. These sentiments are also supported in Daniluk's (2001) work on the long-term adjustment of infertile couples. A heightened sense of worry about their child's health and safety, an increased sense of vulnerability, and higher expectations of themselves as parents may testify to an "indelible imprint of childlessness" (Glazer, 1990, p. 29). The suggestion of a legacy of infertility is also found in the works of Burns (1990) and Sandelowski (1995) based on their studies of perceptions of parenting after infertility and the transition to parenthood after infertility. Both authors describe long-term infertility effects on individuals and couples, in terms of the work previously infertile couples must do as part of making the transition to parenthood (Sandelowski, 5 1995) and related to the long-term impact a history of infertility may have on parenting and family relationships (Burns, 1990). Contrary to the above suggestions regarding a negative long-term legacy of infertility, investigations conducted on the potential effects of conception and parenting following in vitro fertilization (e.g. Golombok, MacCallum, & Goodman, 2001; Greenfeld & Klock, 2001; Van Balen, 1998) suggest relatively positive adjustment of these infertile couples and their offspring. Comparisons between previously infertile couples who had conceived through IVF and couples who conceived without medical assistance have largely supported the psychosocial adjustment of these parents and their child(ren), underscoring the quality of these parent-child relationships for previously infertile parents (e.g. Hahn, 2001; McMahon et al., 1997; Van Balen, 1996). Hahn (2001), in a critical review of the empirical literature, published from 1980 through June 2000, addressing the psychosocial well-being of parents and children born after assisted reproduction, found that there were few significant differences in the functioning of parents and their children born by assisted reproduction compared to that of control families. The author used a computer-based information search on the Psych-INFO and Medline databases to generate potential articles. In order to be included in the review, the study was required to meet certain criteria: (1) the study focused on families with children born by either in-vitro fertilization or donor insemination; (2) the sample size was at least 20; (3) and the dependent variables included one or more of the following: quality of parenting, family functioning, and child development. Despite concerns cited in the earlier writings on parenting after infertility, Hahn discovered that previously infertile mothers who conceived through medical assistance tended to report 6 less parenting stress and more positive parent-child relationships than mothers who conceived without medical intervention or assistance. Abbey, Andrews, and Halman (1994), in their longitudinal study comparing 174 previously infertile couples to 74 presumed fertile couples in their adjustment to parenthood, also found a positive effect for previously infertile women, in terms of an increase in global well-being once they made the transition to motherhood. In summary, relatively little is known about the experience of making the transition to parenthood after a history of infertility. Within the available literature several gaps and inconsistencies are apparent regarding the effects of previous infertility on future parenting and adjustment. Clinicians who work with infertile couples making the transition to parenthood have documented the potential for challenges above and beyond that which is expected for fertile couples (Bernstein, 1990; Garner, 1985; Glazer, 1990). Contrarily, studies exploring the effects of assisted reproduction have concluded that there are few differences amongst couples who conceive following infertility and those who make the transition without medical assistance despite the challenges and stresses inherent in the pursuit of parenthood for infertile couples (Hahn, 2001). Purpose of the Study It is apparent from the available literature that the transition to parenthood entails a significant lifestyle adjustment which can elicit both individual and marital distress (e.g. Cowan & Cowan, 1995; Knauth, 2001). It has also been established that for many, infertility is a significantly challenging life experience (e.g. Daniluk, 2001). However, little is known about the experience of those who make the adjustment to parenthood after a history of infertility and within the literature that is available, there exists 7 numerous gaps and inconsistencies. Therefore, the present study sought to answer the question: " W h a t i s t h e e x p e r i e n c e f o r c o u p l e s m a k i n g t h e t r a n s i t i o n t o p a r e n t h o o d a f t e r p r i m a r y i n f e r t i l i t y ? " In order to understand the specific intention of this study, a definition of terms must be provided. A medical diagnosis of i n f e r t i l i t y is typically given after one year of unprotected intercourse without conception (McShane, 1997) for those under the age of thirty-five and after six months for those over the age of thirty-five (Corson, 1999). Fertility problems can occur after the successful conception and birth of one or more children. This is referred to as s e c o n d a r y i n f e r t i l i t y (Gibson & Myers, 2000). As the t r a n s i t i o n t o p a r e n t h o o d traditionally refers to becoming first time parents (Belsky & Rovine, 1990; Cowan & Cowan, 1995; Levy-Shiff, 1994), this study concentrated specifically on couples who have experienced p r i m a r y i n f e r t i l i t y , that is, a failure to conceive after one year for couples who have never been pregnant (Corson). The t i m e f r a m e for the t r a n s i t i o n t o p a r e n t h o o d can be loosely defined as the point of conception to one year postpartum (Burns, 1990); however, Cowan and Cowan (1992) found that adjustments to parenthood continue well into the second year of parenting. For my purposes, the transition to parenthood was defined as continuing up to two years postpartum. An exploratory phenomenological research design was utilized in order to gain insight into the lived experiences of those making the transition to parenthood after infertility. An in-depth unstructured interview protocol was used to obtain a full and integrated description of the experience (Watkins & Schneider, 1991). The data were analyzed to uncover the main themes in order to provide an "overall description of the 8 meaning and the essence of the experience" (Creswell, 1998, p. 150) of making the transition to parenthood after infertility. The objective of this study was to gain insight into how couples experience " making the transition to parenthood after a history of primary infertility. People who experience infertility represent one of the most invisible populations in our society (Menning, 1982). The lack of literature on the transition to parenthood after infertility suggested that those parenting after infertility might be a neglected group. Therefore, the results of this study were anticipated to help inform theory and practice by filling a gap in the research and by bringing awareness to the experience of a largely unseen population. More important was the potential therapeutic benefit of this research. It was believed that how a person negotiates the developmental transition to parenthood after infertility could positively or negatively affect their sense of self, their marital relationship, their child's development, and the family functioning as a whole. Therefore, an understanding of this experience was expected to be useful to those in the midst of transition, as well as, to any mental health practitioner working with families or individual clients. 9 Chapter Two REVIEW OF THE LITERATURE The focus of this study was the experience and meaning of making the transition to parenthood after a history of primary infertility. In order to provide a context to this exploration an overview of what has been said in the literature about the transition to parenthood and the process of coping with and responding to infertility wil l be discussed. This will serve as a backdrop for the final section of the chapter in which I review both the anecdotal and research-based literature on parenting after infertility. In this section I reflect on what is known and unknown about making the transition to parenthood after infertility and what this may mean for my study. The Transition to Parenthood Over the years, the transition to parenthood and its impact on the individual and the marriage has been studied extensively. While early studies suggest the transition to be a time of crisis (e.g. LeMasters, 1957), more recent works emphasize the adjustment to be a normal developmental event in the individual and family life cycle (e.g. Knauth, 2001; Levy-Schiff, 1994). Regardless of how it is categorized, the transition to parenthood introduces a new set of demands on a couple (Helms-Erikson, 2001) that appear to require significant adaptation (e.g. Cowan & Cowan, 1995). There is little doubt that the arrival and rearing of a first child brings major changes to the daily lives of parents. Loss of sleep, increased expenses often in conjunction with the loss of one parent's income, decreased time for one another and oneself, chronic tiredness, a curtailment of social contacts, and a decrease in marital intimacy are just a few common changes new parents experience (Cowan & Cowan, 10 1992; Miller & Sollie, 1980). While these circumstances may require considerable lifestyle reorganization, it is the pattern of change in the marital relationship that appears to cause the most difficulty (e.g. Cowan & Cowan, 1995; Knauth, 2001). Cowan and Cowan (1992), in a ten-year comprehensive study, investigated marital change during the transition to parenthood. Ninety-six couples were recruited to participate, 72 couples were expecting their first child and the remaining 24 couples were without children. The comparison group of nonparent couples was included to determine whether the transition to parenthood produces change above and beyond the shifts in couple life that inevitably occur over time. Fifteen percent of the participants were black, Asian American, and Hispanic and 85% were Caucasian. A wide range of educational background, socioeconomic status and income was represented. A l l couples participated ; in an initial structured interview at the beginning of the study. An extensive series of questionnaires that had previously been associated with marital satisfaction were administered at different points in time and examined five domains of family functioning: individual, couple interaction, parent-child, three generation, and life stress-social support balance. The researchers found significantly more negative changes in the marital relationship of the new parents than in the childless couples. More specifically, the authors found that during the transition to parenthood men and women became increasingly different from one another with respect to their roles both inside and outside the nuclear family. These contemporary couples tended to fall back on older, more traditional gender-differentiated patterns of adaptation. The investigators concluded that it was those differences that appeared to be associated with a decline in marital satisfaction. The most significant difference between the men and women in the Cowan and Cowan (1992) study was that the gender roles appeared to become more traditional and less egalitarian with respect to the division of household labour and childcare. New mothers disproportionately assumed the required new tasks. Even among couples who, prior to the baby, considered themselves to be equals as far as work and home life was concerned, found that their roles became unbalanced. This finding has been replicated in numerous studies (e.g. Helms-Erickson, 2001; Levy-Schiff, 1994) with the division of labour being considered to be the greatest source of conflict in the marriage (Cowan & Cowan, 1995) and the most problematic and important area of family reorganization for new parents (Knauth, 2001). Despite the persuasiveness of the data from the Cowan and Cowan (1992) study, the findings cannot be generalized to all populations. While their sample did include a wide range of demographic characteristics, it was not representative of the larger population. Families on welfare and from the upper class were not represented, nor were non-English speaking couples. Cultural differences have been found to affect how couples make the transition to parenthood (Levy-Schiff, 1994). Including couples from diverse backgrounds might have strengthened the findings or provided comparative data on factors that might contribute to marital change for couples of different racial, ethnic, and socioeconomic backgrounds. Despite these shortcomings, there seems to be a consensus within ther literature that parenthood introduces a new set of demands that require adaptation on the part of husbands and wives (e.g. Belsky & Rovine, 1990; Levy-Schiff, 1994). However, the effect of these changes on a couple's personal and marital well-being has been debated. 12 Several researchers have found that new parenthood does not necessarily affect all marriages in the same way and that the transition is not necessarily a recipe for marital distress (e.g. Helms-Erikson, 2001, Levy-Schiff, Shapiro, Gottman, & Carrere, 2000). According to these researchers, couples faring relatively well before the transition are more likely to be adapting well after the baby's arrival. In a follow-up article describing interventions to ease the transition to parenthood, Cowan and Cowan (1995) state that the arrival of a first-born child is "unlikely to destroy very well-functioning marriages or generate closer more satisfying relationships between already troubled partners" (p. 415). The difficulty or ease with which a couple makes the transition to parenthood appears to be a function of a variety of influences. Belsky and Rovine (1990) examined variations in patterns of marital change from late pregnancy to 3 years postpartum using an analysis of data collected at four points in time on 128 families rearing a firstborn child. Their analyses revealed that multiple variables, such as demographic, personality, and marital factors, present in the marriage prenatally, might determine the pattern of marital change. A similar sentiment has been expressed based on findings from several other studies (Cowan & Cowan, 1992; Helms-Erikson, 2001; Levy-Schiff, 1994). It appears that some couples may be at higher risk for negative marital change and personal distress than other couples. In a discussion paper on the determinants of marital change during the transition to parenthood, Knauth (2001) outlines several interdependent risk factors for new parents. In particular she points to the individual characteristics of the husbands and wives such as their values, attitudes, and perceptions related to parenting, individual characteristics of the infant, the marital relationship prior to the arrival of the baby, 13 relationships within the multigenerational family, and the division of household labour. Based on her review of the transition literature, Kriauth maintains that, "men and women who have positive attitudes toward parenting and are comfortable with the responsibilities, restraints, and commitments associated with the parenting role.. .experience less decline in marital satisfaction" (pp. 169-170). Based on the available literature, the most powerful predictor of negative marital change during the transition to parenthood appears to be the congruency between one's background, beliefs and behaviours (Helms-Erikson, 2001). Research has shown that gender roles become more differentiated after the arrival of the first child with new mothers assuming the major share of the household maintenance and childcare (e.g. Cowan & Cowan, 1992). However, it is not whether roles become more traditional and less egalitarian that put couples at risk for personal and marital distress, but rather each parent's attitudes about those roles. The literature suggests that the couples who appear to have the most difficulty making the transition to parenthood are those couples whose sex-role attitudes and marital roles do not match (e.g. Levy-Schiff, 1994). Not only are couples with egalitarian attitudes who take on traditional roles at risk but so too are couples with traditional attitudes who take on more egalitarian roles (MacDermid et al., 1990). Couples making the transition to parenthood undoubtedly undergo a life-changing event, however, as has been stated previously in this review, the arrival of the first child is not necessarily a negative experience. In fact, most new parents experience what has been labeled a "baby honeymoon," an initial elation with the experiences related to parenthood (Feldman, as cited in Hobbs, 1965). While this "honeymoon" does not 14 appear to extend past the first few months of the child's arrival, some couples discover coping strategies, such as adaptability and shared responsibility, to assist with the changes to their personal and marital lives (Miller & Sollie, 1980). Previous experiences with developmental transitions, present resources, and a couple's role organization prior to the new arrival are all equally important to parental adjustment (e.g. Levy-Schiff, 1994; MacDermid, 1990). While the effect of parenthood is not the same for all individuals and couples, the available literature does suggest that the transition to parenthood can be a time of increased personal stress and decreased marital satisfaction for many couples. Infert i l i ty For most men and women within North American culture, parenthood is considered to be an important life goal (Daniluk, 1997) and a major developmental milestone (Burns, 1999). However, the desire for a child does not always correspond with one's ability to procreate. Approximately 17% of the reproductive population wil l experience difficulties with their fertility in terms of conceiving and/or carrying a child to term (Leiblum, 1997). Whereas the bearing of a child is considered to be a normative1 role transition (Gibson & Myers, 2000), infertility constitutes an unanticipated developmental crisis with the potential to touch every aspect of a couple's life together (e.g. Eunpu, 1995; Leiblum & Greenfeld, 1997). The experience of infertility is complex. Diagnosis and treatment tends, to be a long and stressful process, especially as it often takes several cycles of treatment over the course of several years before a couple can conceive successfully (Gibson & Myers, 2000). The medical procedures are invasive and can be both painful and disruptive of 15 normal daily fAmctioning (Eunpu, 1995). However, infertility is more than a medical diagnosis (Gerrity, 2001). The literature suggests that various physical, financial, psychological and social stressors can accompany infertility (e.g. Daniluk, 1998; Gibson & Myers), which can ultimately impact the marital relationship (e.g. Domar, 1997), disturb social network systems, and threaten personal well-being (e.g. Gerrity). The stresses of infertility are compounded by the fact that they tend to be experienced over extended periods of time (Eunpu, 1995). Couples often go through repeated cycles of hope followed by disappointment after each failed treatment (Daniluk, 1998). Unlike other medical therapies, the only guarantee of infertility treatment is that there are no guarantees (Gibson & Myers, 2000). Consequently couples tend to find themselves on an emotional roller coaster with each treatment cycle. Many individuals experience a sense of loss and profound grief after every failed treatment (Daniluk, 2001). The losses are abundant and can include the loss of a life goal, one's fertility, a missed experience, the loss of personal and sexual identity, the loss of health, and the loss of relationships (Daniluk; Eunpu, 1995; Gibson & Myers, 2000). Common emotions associated with these losses are profound sadness, depression, helplessness, powerlessness, shame, betrayal, fatigue, anger, loneliness, diminished self-esteem, despair, and a sense of personal failure (e.g. Daniluk; Gibson & Myers; Menning, 1982). The literature suggests that the process of coping with infertility requires people to reexamine every prior expectation for their lives as individuals, as a couple, and as members of society (e.g. Eunpu, 1995). The social expectation is that men and women are suppose to become parents (Gibson & Myers, 2000). This appears to be especially 16 true for women since "motherhood" is considered to be the major role for women in North American society (Gerrity, 2001). The label of infertility can negatively affect one's sense of self (Eunpu) and may require individuals to rework notions of family, femininity, and masculinity (Daniluk, 2001). Infertile couples may question the purpose of marriage (Daniluk), as well as the viability of their marriage especially i f one partner feels responsible for the infertility (Eunpu; Menning, 1982). The available literature suggests that the experience of infertility may be different for men than for women (e.g. Daniluk, 1998; Gerrity, 2001). Nevertheless, it appears that the process of infertility over time is likely to tax a couple's relationship and coping resources, increasing the potential for marital conflict (Gerrity; Gibson & Myers, 2000). Numerous stresses such as difficulties in diagnosis, invasive and painful medical procedures, low probabilities of successful outcomes, and high cost for treatment often contribute to a couple's interpersonal distress (Gibson & Myers). Communication problems may occur, and negative changes in couples' sexual relationship are common (Eunpu, 1995). The pleasure and spontaneity of sexual expression is often taken over by the chronic scheduling of intercourse. It is no longer an expression of affection or closeness, but a required task. For many, this results in decreased sexual satisfaction and for some, sexual dysfunction (Eunpu). Involuntary childlessness can also affect social and familial relationships. Infertile couples often find themselves becoming more and more socially isolated from friends and family over the course of treatment (Daniluk, 1991). Career plans may become delayed (Eunpu, 1995), close friendships may change due to their friends' involvement with their own children (Daniluk, 1998), and infertile couples may avoid 17 attending baby showers, baptisms, and other events that remind them of the pain of their involuntary childlessness. The process of coping with infertility is no doubt personal and varies from couple to couple. Some individuals will be more affected by the process than others based on a wide range of individual, interpersonal, relationship, and medical treatment factors (Leiblum, 1997). However, evidence found in the infertility literature overwhelmingly suggests that the stress of infertility and its treatment can have multiple psychosocial effects and negatively impact personal, marital, sexual, and social relationships (e.g. Daniluk, 2001; Gibson & Myers, 2000; Leiblum & Greenfeld, 1997). It is against this backdrop that the 50% of couples for whom medical treatment is successful, make the transition to parenthood. Research related to the Transition to Parenthood after Infertility In comparison to the large amount of literature that is available on various aspects of the transition to parenthood and infertility, relatively little has been written on the topic of making the transition to parenthood after a history of infertility. Overall, the infertility literature suggests that the experience can entail immense physical, emotional, and marital stress over a relatively long period of time, which for many, can result in significant intrapersonal and interpersonal distress. Similarly, the available literature on the transition to first time parenthood suggests a potential for increased personal stress and decreased marital satisfaction. But are the changes and challenges associated with new parenthood compounded by a history of fertility problems and treatment? Anecdotal and clinical reports appear to suggest that the effects of infertility may persist throughout the pregnancy and beyond the arrival of the child. The first two articles reviewed look specifically at the pregnancy experience for previously infertile couples. Garner (1985), in the landmark article on pregnancy after infertility, speculates that the achievement of pregnancy, for many, does not eliminate the emotional aspects of infertility but instead brings forth new anxieties that can complicate the pregnancy and postpartum experience. The purpose of Garner's article was to sensitize nurses to the i i unique needs of previously infertile couples who have achieved pregnancy and to suggest possible nursing interventions. Her article is written as a guide for perinatal nurses working with previously infertile couples and outlines a variety of possible responses to pregnancy after infertility. Although, the author does not specifically address the possible effects of infertility on the transition to parenthood, she does suggest that the difficulties associated with pregnancy after infertility must be confronted in order to make a smooth transition to parenthood. Garner (1985) states that many patients will have exaggerated fears related to the pregnancy due to the trauma of previous pregnancy losses or disappointments. She alleges that some patients may cope with these fears by denying their pregnancy while others may experience a sense of ambivalence or a "lack of feelings" (p. 61) throughout their pregnancy. The author also states that because pregnancy has been a major goal in the lives of infertile couples, they may avoid acknowledging the unpleasant realities of pregnancy, such as fatigue, nausea, and weight gain and instead idealize pregnancy and parenthood. Garner suggests that some couples believe that the expression of negative feelings would make them "appear ungrateful and less than perfect parents" (p.60). Elements of psychosocial distress associated with the infertility experience such as 19 marital discord, lowered self-esteem, financial worries, and increased isolation may also continue to be of concern, according to Garner. Patients, adapting to a new pregnancy, may not have an opportunity to properly resolve any residual outcomes of infertility. This can put couples at risk for psychologic distress both during and after the pregnancy. While the author does state that many couples will have no trouble adapting to pregnancy and parenthood after infertility, Gainer believes that infertile couples can enter pregnancy with past experiences and feelings that may increase the normal stresses of pregnancy and ultimately greatly affect their parental role development. While Garner's (1985) article is thought provoking, it is not research-based and is therefore limited. Although the author appears to write with authority, it is unclear whether the information has come from observations in her own practice or is simply based on possible conclusions drawn from her review of the infertility and the pregnancy literatures. Despite these limitations, however, Garner's article stimulated an interest in the possible effects of infertility on pregnancy and future parenting. In a similar vein with Garner (1985), Olshansky (1990) addresses the topic of pregnancy after infertility and its implications for nursing practice. The purpose of her article was to review the existing literature in order to gain knowledge that might assist nurses in caring for couples who have previously struggled with infertility during pregnancy, the birthing process, and postpartum. Based on this review, Olshansky reports potential difficulties similar to those identified in Garner's article. However, Olshansky discusses the postpartum period in greater detail, describing it as a time for complex emotions. She suggests that a couple's prior struggles with infertility may exacerbate the feelings of fatigue experienced by most new parents and make it more difficult to come to terms with the profound changes a baby has on parents' lives. The author proposes that this can put these new mothers at additional risk for postpartum depression. Finally, Olshansky indicates that as previously infertile couples get to know their new babies they may have difficulty reconciling the idealized vision of parenthood they experienced during their time of infertility with their present reality. Olshansky (1990), based on her own ongoing research with previously infertile pregnant women and the literature reviewed, proposes that previously infertile couples have difficulties above and beyond those of other pregnant couples because of the "identity shift" they are required to make from 'self as infertile' to 'self as pregnant.' She suggests that this transition is not necessarily neat and orderly. For many of the infertile women who become pregnant, "their experience is that they have one foot in the fertile world and one foot in the infertile world, not being completely comfortable or accepted in one or the other" (p.343). The author states that some couples never "give up" their identity as infertile, especially those who believe they "circumvented" infertility through assisted reproduction. It is possible therefore, that these issues during pregnancy, i f left unresolved, might continue throughout the transition to parenthood. The timeframe for the transition to parenthood is typically defined as the point of conception to two years postpartum (Burns, 1990; Cowan et al., 1985). While the Garner (1985) and Olshansky (1990) articles do not specifically address parenting after infertility, they do look affile beginning of the transition to parenthood and suggest that the difficulties inherent for most couples during this period may well be exacerbated by a history of infertility. However, because these articles are largely based on anecdotal 21 information, more research is needed. The following articles will look specifically at the postpartum period. Bernstein (1990), based on her own clinical experience as an in vitro fertilization nurse manager, as well as on clinical evidence compiled by nurses, psychologists, and physicians, suggests that couples with a prior history of infertility have unique difficulties and special needs as they make the transition to parenthood. As with Garner (1985) and Olshansky (1990), Bernstein's purpose was to provide guidelines and recommendations for clinical nursing practice. Bernstein outlines the potential effects of infertility on the transition to parenthood. They include increased anxiety levels during pregnancy and preadoption, difficulty in assuming maternal/paternal roles, possible delayed bonding, cognitive dissonance from a gap between their 'ideal' and 'real' self and between their 'fantasy' and 'real' child, and ethical and emotional issues related to assisted reproduction, adoption, and third party donation. The author also outlines potential factors affecting parenting. These include decreased self-esteem, an altered body image, self-concept, impaired marital communication and sexual intimacy, isolation from family and friends, and grief over losses associated with infertility such as, anxiety, depression, and anger management issues. Bernstein (1990) acknowledges.the lack of empirical studies on the topic of making the transition to parenthood after infertility. Although, her article is based on detailed clinical experience, she recognizes that the generalizability to a larger population is very limited. However, with these limitations in mind the author does suggest some possible interventions that might help to facilitate the transition to parenthood but 22 recognizes the great need for further investigations. Numerous recommendations for future research are listed at the end of the article. Similarly, Burns (1990), in her exploratory study of perceptions of parenting after infertility, suggests that how a couple adjusts to the trauma of the infertility crisis will have an impact on the family's subsequent functioning. The purpose of the study was to examine the long-term effects of infertility on the psychosocial functioning of families and/or children. Specifically, the researcher sought to answer the question: Does infertility leave in its wake a unique legacy for families and children? A group of 20 infertility-treated women were compared on their perceptions of their parenting to a group of 10 women without a history of reproductive failure. The husbands were invited to participate but only 6 agreed to be interviewed from the infertility treated group and 3 from the comparison group. The concept of a continuum of parenting outcomes ranging from neglectful/abusive parenting to child-centered/overprotective parenting with the midrange representing positive parenting was used to assess parents' perceptions. In an interview, subjects were asked to describe their infertility experience and the place it had in their lives. These semi-structured interviews were transcribed verbatim and coded by themes by two raters. Interrater reliability was cited to be strong. The participants were also asked to complete a paper-and-pencil measure that consisted of items adapted from other measures designed to discriminate between overprotective/child-focused parenting and abusive/neglectful parenting. The subjects then were asked to rate themselves and their spouses on the parenting continuum. If the interviewee rated either themselves or their spouse as overprotective/child-centered or abusive/neglectful, the couple was assigned to that category. ; " 2 3 Analysis of the data indicated that 85% of the subjects rated infertility as having been a negative experience and 80% of families with a history of reproductive failure rated their parenting as either overprotective/child-centered, abusive/neglectful, or both. Only 20% of these subjects rated their parenting as conscientious/secure. Burns (1990) therefore concluded that families with a history of infertility may experience more problems in themselves, their marriage, their parenting, and in their children as compared to families without fertility issues. The strength of this study by Burns (1990) is that it challenges the idea that infertility is a transient problem with a baby being the solution. It also identifies potential issues in a typically overlooked population. The findings, however, lack credibility due to an abundance of weaknesses in the study. The first limitation is the small sample size. Even more notable is the lack of information on the experiences and perceptions of infertile men. The instrument used to measure parenting styles was, according to the author, both rudimentary and ineffective. It was created by the researcher and was not tested for its effectiveness prior to the study. The idea of a continuum may have been too simplistic. The paper-and-pencil measure also lacked robustness, as it was a compilation of items taken from several other measures. The reliability and validity of the measure was undetermined. Finally, another potential weakness is that there may have been a cohort effect in that the participants were all treated for infertility before 1976. The experience of infertility prior to more current medical advancements and when the possibility for adoption was greater may well be different than the treatments and circumstances more commonly experienced today. 24 Bums (1990) was interested in the effect of infertility on future family functioning rather than on the transition to parenthood itself. The applicability of this study to my research interest is limited because the infertile participants did not necessarily experience primary infertility, were not first-time parents, and had children over 10 years of age on average. In addition, the majority of the subjects had become parents through adoption, and research has suggested that the transition to parenthood for adoptive parents may be different from that of biological parenthood (Levy-Schiff, Goldshmidt, & Har-Even, 1991). As with the Burns (1990) study, Dunnington and Glazer (1991) use empirical research methods to investigate the potential impact of prior infertility on parenting. The investigators report findings from a descriptive pilot study with six previously infertile women, ranging in age from 28 to 41 years and five never infertile women, ranging in age from 26 to 40 years. The women were required to meet specific demographic criteria in order to be eligible for the study. The participants were married, over 20 years of age, having never before given birth, medically low-risk, and had delivered healthy full-term babies. A l l participants were white and from similar socio-economic backgrounds, however, the previously infertile women tended to have more years of education than the never infertile women. The purpose of the study was to "form a beginning understanding of the transition from infertility to early motherhood" (p. 309). Three specific objectives of the study were: (1) the comparison of maternal identity in previously infertile and never infertile women during the prenatal and postpartum period; (2) the comparison of mother-infant interaction and environmental support in the home; and (3) an examination of the relationship of maternal identity and early mothering behaviour in both groups of 25 mothers. The study was both quantitative and qualitative in nature as the women were tested by questionnaire, observed, and interviewed. The researchers used three measurement instruments. Maternal identity was measured by using Walker 's semantic differential scales, M y s e l f as Mother and M y Baby. The Nursing Chi ld Assessment Feeding Scale ( N C A F S ) was used during a natural feeding session to assess mother and infant interactions. Finally, The Home Observation for Measurement o f the Environment ( H O M E ) was administered to assess environmental support. This scale was completed by observation and interview. The study was conducted in two portions, prenatal (between 36 and 40 weeks gestation) and postnatal (4 r to 6 weeks postpartum). Demographic information was collected and the Myse l f as Mother questionnaire was administered prenatally at one of five private obstetric offices. During the postnatal home visit, the primary investigator administered the Myse l f as Mother and M y Baby questionnaires, recorded feeding observations on the N C A F S and interviewed the subjects according to the H O M E scale. The following three questions were also asked at the end o f the session: (1) how did you feel about your pregnancy?, (2) when did you start getting items for the baby?, (3) how did you feel about yourself as a mother during these first weeks at home together? Dunnington and Glazer (1991) found that never infertile mothers showed a strengthening in maternal identity across the testing period, whereas previously infertile mothers showed a weakening in identity resulting in lower self-evaluations and infant evaluations. Three themes emerged for the previously infertile women from the interview data: denial, poor self-confidence, and identity confusion. Denial of the pregnancy was used by previously infertile women as emotional protection. These r 26 women also expressed a lack of self-confidence in their ability to perform mothering tasks and experienced more identity confusion between career and maternal identities than did never infertile women. Qualitative interview data also reflected an intentional postponement of home environment preparation by previously infertile women. The findings from the Dunnington and Glazer (1991) study appear to substantiate claims made by Garner (1985), Olshansky (1990), and Bernstein (1990). Negative effects of infertility may persist throughout pregnancy and during the postpartum period. Exaggerated fears during pregnancy, lowered self-esteem and self-efficacy, and difficulty assuming the maternal role are also themes reported in the earlier speculative articles. The inclusion of a group of women without a history of infertility strengthened the researchers' conclusions by providing a comparison. However, due to several limitations, the results cannot be generalized. The sample size was very small and included only Caucasian participants. The cultural diversity of the general population was not represented. The findings of the study were also limited to women. Despite the fact that infertility is a couple's problem (Daniluk, 1997) and that both parents participate in, and are required to make the transition to parenthood, no data was collected on paternal identity or father-child interaction. Finally, only one observer was used in the home visits, which may have been a source of potential bias. Despite these limitations, however, the researchers were successful in their main objective, to form a beginning understanding of the transition from infertility to early motherhood. Contrary to the anecdotal and empirical accounts that suggest infertility places couples at risk for difficulties in making the transition to parenthood (Bernstein, 1990; Dunnington & Glazer, 1991; Garner, 1985; Olshansky, 1990), Abbey, Andrews, and 27 Halman (1994) found that becoming a parent after infertility might actually increase a person's well-being. In a longitudinal, quantitative study, the researchers interviewed the husbands and wives in 174 infertile couples, as well as a comparison group of 74 presumed fertile couples. A l l couples were white, childless at the beginning of the study, and middle class, however members of infertile couples were on average two years older arid had been married four years longer. Presumed fertile couples were required to have no known problems associated with infertility and a desire to have children in a few years. After the initial one-hour in-person interview, follow-up telephone interviews lasting 40-minutes were conducted 1 and 2 years later. The purpose of the study was to "examine the impact of becoming a parent on members of infertile couples" (p.398). The measures used in the Abbey et al. (1994) study included a broad range of concepts found within the infertility and transition to parenthood literatures. Global life quality, fertility or biggest problem stress, intimacy life quality, spousal conflict, home life stress, and negative affect are examples of the variables included. It was hypothesized that, as reported in the transition to parenthood research, members of both groups who eventually made the transition to parenthood would experience increased home life stress, reduced marital intimacy, and less frequent sexual intercourse with women exhibiting more stress and dissatisfaction associated with parenting than men. Abbey et al. (1994) state that initial one-hour interviews were conducted in-person by professional interviewers, although there is no information on who these interviewers were or how they were trained. Husbands and wives were interviewed separately, usually on the same day. Follow-up 40-minute telephone interviews were conducted 1 and 2 years later. By the two-year mark, 42% of the infertile couples had 28 become parents through pregnancy or adoption. Six of these couples had multiple births, one couple had adopted twins, and another six couples had already become parents for a second time. Thirty-six percent of the presumed-fertile couples had become parents. Among this group of participants there were no multiple births, adoption, or medical interventions and only one couple had become parents for a second time. Analysis of the data revealed that becoming a parent produced an increase in global life quality solely for previously infertile women. Diminished marital well-being and other negative effects were expressed by all new parents, a finding not unlike that indicated in the transition to parenthood literature (e.g. Cowan & Cowan, 1995; Knauth, 2001); however, previously infertile women did experience additional positive effects to their psychological well-being. While infertile men who became parents experienced the same negative effects reported by their wives, they did not experience positive effects to the same extent. In fact, previously infertile men experienced greater home life stress compared to their wives, fertile parents, and nonparents. Abbey et al. (1994) not only concluded that having a child increased the overall well-being of previously infertile women but that it might actually mitigate the negative effects of infertility for some women. This finding is strikingly different from prior anecdotal and clinical reports (Bernstein, 1990; Garner, 1985; Olshansky, 1990). A benefit of the Abbey et al. (1994) study is that it takes into account the experience of both husbands and wives. It also provides useful comparisons between parents and nonparents, as well as fertile and infertile couples who parent or remain childless. These comparisons allow conclusions to be drawn based on differences found 29 amongst groups. The conclusions; however, need to be considered with some degree of caution. The findings of the Abbey et al. (1994) study appear to be encouraging for previously infertile women. The same however, cannot be said for previously infertile men. The findings do not necessarily dismiss prior claims that the negative effects of infertility persist throughout the transition to parenthood, at least for fathers. Another limitation is in the way in which children entered the families. Regardless of their history of infertility, the experience of new parenthood was potentially different for the infertile group due to factors associated with adoption or multiple births. Research has demonstrated that the experience of parenting multiples is different from that of singletons (e.g. Holditch-Davis, Roberts, & Sandelowski, 1999; Weigel, Auxier, & Frye, 2000). Adoption literature also suggests that processes underlying the transition to parenthood in adoptive and biological families differ from one another (e.g. Levy-Schiff et al., 1991). Finally, the researchers included data from couples who had become parents a second time despite the fact that the transition to parenthood traditionally refers to becoming first time parents (Burns, 1990). Nevertheless, the findings from this study challenge the assumption that stresses inherent in the transition to parenthood are negatively compounded by prior experiences of infertility. Similarly, the findings from Allen, Maguire, Williams, and Sanger's (1996) quantitative study on the effects of infertility on parent-child relationships and adjustment provides further data that may refute earlier speculation by Garner (1985) and others about the negative impact of infertility on future parenting. The purpose of this study was to "assess the impact of past infertility on the parent-child relationship and child 30 behavior" (p.94). Three specific objectives were explored: whether a history of infertility puts mothers at increased risk for parenting distress, whether past infertility impacts parent-child relationships, and whether children of previously infertile mothers are at risk for developing behavioral adjustment difficulties. Three measures were administered to 45 previously infertile mothers, ranging in age from 27.to 46 years. These included the Parenting Stress Index (PSI), which measures the relative magnitude of stress in the parent-child system, the Achenbach Child Behavior Checklist (CBCL), which measures the presence of specific emotional and behavioral problems in children, and background information which included items such as, fertility history, age, and socioeconomic status. A l l three measures were either evaluated directly by self-report or by parental report. These measures were also administered to a control group of 45 mothers, ranging in age from 26 to 43 years, who had voluntarily delayed pregnancy for at least one year. At the time of data collection the mean age for the children was 3.1 years for the infertile group and 3.4 years for the control group. Both groups were exclusively white, with the average family falling within the minor professional and technical social strata (Hollingshead, 1975). The results of this study suggest that the transition to parenthood for those who involuntarily delayed pregnancy is no more challenging than for those who voluntarily delayed pregnancy. The notion that a history of infertility puts parents at increased risk for parenting difficulties was not supported. Allen et al. (1996) found that previously infertile mothers did not report significantly greater adjustment problems for themselves or their children. In fact, it was the control group who reported higher scores on several aspects of the PSI indicating that they felt more restricted, isolated, and unsupported than 31 the infertile group. The researchers noted that many of the women with a history of infertility reported anecdotally that they were so thankful for their child that it positively affected the quality of their relationship with their offspring. This sentiment may be seen to substantiate the findings of Abbey et al. (1994) in that becoming a parent mitigated the negative effects of infertility. Once again, the generalizability of these findings is limited to white members of society within a specific economic background. The findings are also limited to women. Allen et al. (1996) reported that the experience of infertility did not affect future parent-child relationships. More accurately, the investigators should have stated that infertility did not affect mother-child relationships, as fathers were not included in the study. Holditch-Davis, Sandelowski, and Glenn Harris (1998) reported findings on the early parent-infant interactions of infertile couples who became parents through pregnancy or adoption as compared to couples without fertility problems. The study included 30 infertile couples with biological children, 21 couples with a history of infertility who adopted, and 19 fertile couples. A l l couples were subjects in a larger study on the transition to parenthood for infertile couples. Couples were recruited from a variety of sources such as infertility clinics, obstetricians' offices, adoption agencies, and by personal contacts. Couples who had multiple births or who adopted children older than 6 months were excluded from this analysis. A l l couples, including those who were fertile, met the demographic characteristics typical of those who seek treatment for infertility in North America: white, married, in their late twenties to thirties, and of middle-to upper-middle class. 32 Two observations of mother-father-infant interactions were conducted in participant's homes. The first observation took place 7 to 21 days after the infant's arrival home and the second a week later. The second observation was used to assess the reliability of the initial observation by determining whether the variables recorded at the first observation were typical for the families. Two observers conducted the observations at a time when both parents were home and at the time the infant would be receiving a feeding. Inter-rater reliability was checked on an ongoing basis and found to be high. Behaviours of the mother, father, and infant were recorded every 10 seconds, beginning when the baby was picked up and ending when the baby fell asleep or after 1 Vi hours had passed. Several parental behaviours, such as touch, movement, rocking, talking, eye to eye contact, and games playing were recorded. Interaction context based on who was interacting with the baby, such as mother only, father only, both parents, or no one interacting was also included in the analysis. Infant sleep-wake states and behaviours were also studied. Data analysis of the behaviours and interactions measured suggest that neither infertility nor adoption negatively impairs early parenting. Parents from all three groups spent similar amounts of time in the different types of care giving. Adoptive parents were found to hold and touch their infants less than biological parents despite exhibiting increased amounts of some positive parenting behaviours, such as eye contact and game playing. However, the researchers suggest that these differences in behaviour may be best explained as responses to the behaviours of older infants, rather than evidence of . poor parenting. The babies of couples who adopted tended to be older than the newborns of the other infertile couples. 33 In concordance with other studies investigating the impact of infertility on variables related to the transition to parenthood (Abbey, et al., 1994; Allen et al., 1996), Holditch-Davis et al. (1998) conclude that a history of infertility does not necessarily have a negative effect on later parenting. The inclusion of an adoption group increases the generalizability of the findings since numerous infertile couples wil l make the transition to parenthood after adoption. The validity of the conclusion is also strengthened by the inclusion in the study of both mothers and fathers. Numerous studies have been limited due to an under representation of the male experience (Dunnington & Glazer, 1991; Allen etal.). However, despite the apparent strengths of the Holditch-Davis et al. (1998) study, several limitations exist. The generalizability of the findings is once again limited to those with similar demographic characteristics. Of even greater concern, is the possibility for biased results due to the parents' awareness that they were being observed. The couples were not blind to the purpose of the study, nor were they unaware that they were being observed. Whether or not their behaviours were typical of those exhibited when alone with the infant is hard to determine. Finally, the observations were made very early on in the parenting process. Research has shown that the effects of the transition to parenthood continue well into the second year postpartum (Cowan et al., 1985), therefore it is difficult to conclude whether this apparent lack of an effect of prior infertility on parenting continues as the child matures. Sandelowski (1995) presents a theoretical synthesis of the transition to parenthood of infertile couples that was derived from three studies of infertility the author and her colleagues conducted between 1985 and 1993 (the methodology can be found in 34 Sandelowski, Holditch-Davis, and Harris, 1992). Much of the theory is drawn from a longitudinal, field study and grounded theory investigation of the transition to adoptive or biological parenthood of 75 infertile couples (39 couples who conceived spontaneously or through biotechnical means and 36 couples waiting to adopt) and a comparison group of 20 fertile couples. A l l couples shared similar demographic characteristics and were primarily white (1 Hispanic woman), married, and middle-income. The purpose of the study was to describe the "pregnancy, adoption waiting, and early parenting experiences" (p.301) of couples with a history of infertility. A specific long-term objective was to provide health professionals who work with couples experiencing fertility impairments, with a theoretical basis for practice. Numerous conjoint interviews were conducted at comparable points in time in the childbearing and adopting couples' transition to parenthood. Fertile and infertile childbearing couples were interviewed in their homes three times during the pregnancy (by 12 weeks, and around 22 and 37 weeks) and twice after delivery (within 1 week of the infant's arrival home and 3 months later). Adopting couples were interviewed in a similar fashion every 4 months until placement and then within 1 week and 3 months after the child's arrival home. Two of the investigators conducted the interviews and each couple had the same interviewer throughout the study. The interviews were intensive but efforts were made to create a comfortable atmosphere conducive to free expression. The first interview had couples telling the story of their infertility or impending parenthood. In subsequent interviews, couples were asked to talk about what happened since the last interview. The timeframe for each interview was not predetermined as couples were allowed to reach a natural conclusion to their discussions. t 35 Interviews were transcribed verbatim and brief notes about the interview were added at the end by the interviewer. Sandelowski's (1995) theory describes processes that all couples making the transition to parenthood experience, regardless of their fertility status. In addition to this overlapping work, the author outlines reconstructive and repair work exclusive to infertile expectant and new parents, as well as special work for different groups of infertile couples. According to Sandelowski (1995) and colleagues, the process of the transition to parenthood for previously infertile parents requires added physical, emotional, and interpretive work of recovery, repair, and reconstruction. The process includes four different tasks: (1) facing infertility - the process of revealing, concealing, and accommodating the social consequences of infertility; (2) mazing - the recursive, iterative, and capital-intensive process of the pursuit of parenthood; (3) relinquishing infertility - the effort to divest themselves of their infertile identity, thoughts, feelings, and behaviour patterns; and (4) reconstructing infertility - the process in which a couple seeks to understand and gain interpretive control of their infertility experience. In addition to the four tasks outlined above, special work appears to be required of different groups of infertile couples. Adoptive couples face two additional tasks: (1) creating temporal order — the process of "pacing" the waiting period by setting forth goals, such as careers, vacations, and home improvements; and (2) reconstructing a family romance - the process by which adoptive couples create a biography for their child that fits with their own. According to Sandelowski (1995), couples conceiving with biomedical assistance may need to resolve conceptual ambiguity, which entails the 36 process by which women seek to determine the type of pregnancy they had achieved. Finally, both adoptive couples and those who conceive through donor gametes appear to face the additional task of staking a claim. This involves the couples' efforts to own a child biologically unrelated to one or both partners. The studies upon which this theory is based have numerous strengths. According to Sandelowski (1995), this theory is grounded in the lived experience of infertile couples and captures "the essence or nature of the transition itself (p. 130). Previous studies have focused on specific features of the transition in order to provide evidence for or against the claim that the effects of infertility might negatively impact future parenting (e.g. Abbey et al., 1994; Bernstein, 1990, Dunnington & Glazer, 1991). Contrarily, these investigators sought to describe the experiences of couples with fertility impairments, not to prove or disprove prior claims. The theory is also useful in its comprehensiveness. By spanning the expectancy through early parenting periods and by contrasting the transition to parenthood between fertile and infertile couples, as well as among different groups of infertile couples, the theory provides practical information for a variety of circumstances and clientele. Finally, since men have historically been underrepresented in infertility studies, the use of conjoint interviews further strengthens the findings. The perspectives and experiences of both members of the couple were considered in the generation of the theory. Despite the apparent strengths of the theory, a few qualifications must be acknowledged. Infertile couples making the transition to parenthood after secondary infertility were included in the study from which the theory was generated. These couples had successfully conceived and given birth one or more times before 37 experiencing difficulties with their fertility. While these couples could provide information on the experience of parenting after infertility, they were not making the transition to first-time parenthood. The number of couples included who were experiencing secondary infertility was not stated. Another aspect of the theory that needs qualifying is that it only encompasses the period of expectancy or waiting-to-adopt to three months after the baby's arrival home. Research has shown that the transition to parenthood continues well into the second year postpartum (Cowan et al., 1985). The inclusion of the experiences of previously infertile couples parenting after a year or more of the baby's arrival home could potentially broaden the theory and more accurately reflect the experience of making the transition to parenthood after infertility. Hahn (2001) critically reviewed the empirical literature published from 1980 through June 2000 on the psychosocial well-being of parents and their children born after assisted reproduction. The author used a computer-based information search on the Psych-INFO and Medline databases to generate potential articles. In order to be included in the review, the study was required to meet the following criteria: (1) the study focused on families with children born by either in-vitro fertilization or donor insemination; (2) the sample size was at least 20; and (3) the dependent variables included quality of parenting, family functioning, and/or child development. These variables are similar to those examined in much of the parenting after infertility literature. The studies tended to include comparison groups of fertile parents, as well as infertile couples who had become parents without the use of assisted reproductive techniques (e.g. through adoption, drug therapy, or spontaneous conception). 38 The findings from Hahn's (2001) literature review are reassuring for infertile couples that are contemplating assisted reproductive techniques. The investigator found that overall, the "psychosocial functioning of parents and their children born by assisted reproduction is more similar than dissimilar to that of the control families" (p.530). In fact, previously infertile parents with children born using IVF or donor insemination (DI) tended to report less parenting stress and more positive parent-child relationships than control parents. Hahn (2001) points out a few caveats regarding the conclusions, which were , largely based on self-report measures. First, the findings may reflect a more positive conclusion than what is true in reality as parents of children born using assisted reproduction might feel that they should not display anything other than gratefulness about something that they have wanted for so long. Second, the design of most of the studies reviewed could not exclusively determine whether group differences were a function of the assisted reproductive technique or of the experience of infertility in general. Third, the couples that conceived their children by IVF or DI were not a heterogeneous group. The same could be said about all infertile couples. Infertility is a complex process and differs enormously from one couple to the next. Finally, most of the studies reviewed focused on "traditional" two-parent, middle-class families and therefore did not represent or reflect the variety of individuals and couples undergoing assisted reproductive techniques. Regardless of these potential limitations, however, Hahn's review provides further evidence that contradicts initial concerns (Garner, 1985; Olshansky, 1990) about the negative consequences of infertility on future parenting. 39 In summary, relatively little research has been conducted on the experience of making the transition to parenthood after a history of infertility. Several articles, based solely on anecdotal and clinical evidence, have suggested that previously infertile couples may experience unique challenges adjusting to parenthood as compared to couples without a history of fertility impairment (Bernstein, 1990; Garner, 1985; Olshansky, 1990). Empirical studies have had inconsistent results. Some suggest that the negative effects of infertility may persist throughout pregnancy and postpartum, and ultimately impact the family's future functioning (Burns, 1990; Dunnington & Glazer, 1991). Other studies refute the notion of a negative impact of infertility on future parenting (Abbey et al., 1994; Allen et al., 1996; Hahn, 2001; Holditch-Davis et al., 1998). While the latter findings challenge the popular notions of increased difficulties and appear to represent good new for those parents who have struggled with infertility, these studies do not describe what the experience is like from a couple's perspective, to make the transition to biological parenthood following a history of infertility. This study attempts to describe this experience over the first 2 years of the transition and its meaning for infertile couples. 40 Chapter Three METHODOLOGY The purpose of this qualitative study was to examine the lived experience of couples who make the transition to parenthood after primary infertility. Phenomenological interviews were conducted in order to obtain a full and integrated description (Watkins & Schneider, 1991) of the experience. Participants' descriptions were analyzed for deep meaning structures and then formulated into a cluster of themes that characterized the phenomenon across multiple cases (Colaizzi, 1978; Osborne, 1990). Research Design Method Selection Relatively little research had been conducted on couples who make the transition to parenthood after prolonged infertility. Within the available literature there were several gaps and inconsistencies; therefore, in order to gain insight into this experience, I utilized an exploratory phenomenological research design. The purpose of the phenomenological method is not to explain or analyze but to describe a phenomenon as precisely and completely as possible (Kvale, 1983). The aim is the elucidation of meaning and understanding of human existence from an individual's point of view (Osborne, 1990). This is done through an exploration of the individual's inner world of values, beliefs, and personal meanings. It is a descriptive science that endeavors to "contact the phenomenon as people experience it" (Colaizzi, 1978, p.57). Phenomenology represented a useful approach for exploring the research question: What is the experience for couples making the transition to parenthood 41 a f t e r p r i m a r y i n f e r t i l i t y ? The existing research that had explored the transition to parenthood after infertility was limited. Articles based solely on anecdotal and clinical evidence lacked rigor and the handful of empirical studies showed inconsistent results. In addition, the existent literature on parenting after infertility failed to illuminate couples' lived experience of making the transition to parenthood after a history of infertility. The present study invited participants to describe their experience and meaning-making in their own voices. Narrative accounts were generated through minimally structured interviews. These descriptions were then reviewed for universal meanings; which revealed the overall essence of the couple's experience of making the transition to parenthood after a history of primary infertility. Personal Assumptions and Bracketing Knowledge coming from phenomenological research cannot be purely objective (Colaizzi, 1978). The researcher's prior understanding of the phenomenon, his or her personal interests, and frame of reference unavoidably bias the formulation of the research question, data collection, and its interpretation. Phenomenological knowledge is in fact, perspectival (Osborne, 1990). It is an intuitive process that requires both creative insight and meaning making by the researcher (Colaizzi). Despite the impossibility of objectively eliminating one's own experience, care can be taken to faithfully present the phenomenon with as much accuracy as possible. Through a process of "rigorous self-reflection" (Osborne, p.81) known as bracketing, the researcher endeavors to continually identify his or her own presuppositions about the nature of the phenomenon and attempts . to set them aside as much as possible (Osborne, 1994). The researcher makes his or her beliefs, assumptions, and biases known to the reader so that that the reader can take this 42 perspective into account when evaluating whether the study has been true to the participants' lived experience. Through the process of bracketing the researcher refuses to tell the phenomenon what it is and seeks to respectively listen "to what the phenomenon speaks of itself' (Colaizzi, p.52). M y interest in and presuppositions about making the transition to parenthood after infertility were informed by my personal experiences, as well as by my review of the infertility literature, the transition to parenthood literature, and the parenting after infertility literature. On a personal level, the experience of infertility has been a part of my awareness since I can remember. Infertility has touched the lives of several family members and friends, including my own parents. The process of infertility, including the adoption of my older sister and my "surprise" arrival, is a part of my family's story. It is my belief that the infertility experience also played a significant role in my family's functioning, although it is difficult to disentangle the infertility experience from the different ways in which my sister and I entered the family when assessing the impact on our family functioning. Nevertheless, the infertility experience certainly helped to shape my beliefs, values, and attitudes. The idea of a "legacy of infertility" (Burns, 1990; Garner, 1985; Glazer, 1990) makes sense to me. Despite the fact that it was my parents who experienced infertility, I fully expected to have difficulties conceiving. I did not take my fertility for granted. This personal "fear" of infertility was a decisive factor in my resolution to start a family while in the midst of an intensive Masters degree program. Even though my fear was proven needless when I conceived without difficulty, I continue to be plagued with the fear of an inability to conceive. 43 M y interest in making the transition to parenthood after a history of infertility was further shaped by my own transition to parenthood. I could personally attest to the unique changes and challenges that a first-born brings to an individual, the marital unit, and the extended family. In addition, seven months after the birth of my daughter, my closest friend became pregnant through in-vitro fertilization after a grueling eight years of fertility treatment. Through this relationship I became further aware of the many challenges faced by couples experiencing involuntary childlessness and of the presence of anxieties above and beyond that which I had experienced during my own pregnancy. While struggling with my own transition to motherhood, I Often found myself wondering what my friend's transition would be like, whether it would be more difficult or just different. And judging from my friend's joy and excitement over the news of her pregnancy, I also wondered whether it would be easier. M y presuppositions about making the transition to parenthood after a history of infertility reflected both my personal experiences and my review of the relevant literature. First, consistent with infertility research (e.g. Domar, 1997; Eunpu, 1995; Gerrity, 2001) and my friend's experience of coping with infertility, I assumed that for many couples, the process of infertility could produce considerable stress and have multiple psychosocial consequences. Second, in accordance with my personal journey to parenthood and the transition to parenthood literature (e.g. Cowan & Cowan, 1995; Levy-Schiff, 1994; Shapiro, Gottman, & Carrere, 2000), I assumed that new parenthood entailed a significant lifestyle adjustment. Given the first two presuppositions, I expected that the experience of coping with infertility would impact a couple's transition to parenthood. More precisely, I expected 44 that the experience of making the transition to parenthood after infertility would have both similarities to and differences from those who make the transition without, fertility impairment. A final presupposition reflected the fact that infertile couples are not a homogenous group. Every couple has a different story. The number of years pursuing parenthood, the types of medical procedures undertaken, the number of miscarriages experienced, and the marital relationship prior to and during the process of infertility are just a few of the ways in which couples experience infertility differently. This being said, I expected diversity in the couple's experience of making the transition to parenthood after infertility. Furthermore, consistent with the transition to parenthood literature (e.g. Cowan & Cowan, 1995; Levy-Schiff, 1994; Shapiro, Gottman, & Carrere, 2000), I expected that men and women's experiences in adjusting to parenthood after infertility might be different from one another. Finally, I expected that those couples who experienced the greatest amount of strain in their marriage during the process of coping with infertility might have more difficulty making the transition to parenthood than those with less marital strain. Research Procedure Participants Phenomenological research is an investigation of human experience (Colaizzi, 1978) that seeks to elucidate meaning and understanding from an individual's point of view (Osborne, 1990). As the aim of phenomenology is a rich description reflective of genuine experience, ideal participants are those who are able to articulate the phenomenon of interest (Colaizzi) and have a personal interest in illuminating the 45 phenomenon in question (Osborne, 1994). Participants are always volunteers and in order to emphasize the co-operative nature of the research, they are viewed as "co-researchers," and were viewed as such in this study. Criteria Participants were invited to reflect on their experiences in making the transition to parenthood after a history of primary infertility. Participants were previously infertile couples in the midst of making this transition. More precisely, the couples were first-time parents with only one child. Couples who had become parents for a second time were excluded from the study as the transition to parenthood traditionally refers to becoming first-time parents (Burns, 1990). Parents of multiples were also excluded from the study because research has suggested that the transition to parenthood for parents of multiples may be different from that of singletons (e.g. Holditch-Davis, Roberts & Sandelowski, 1999; Weigel, Auxier, & Frye, 2000). Research has also demonstrated that the effects of the transition to parenthood continue well into the second year postpartum (Cowan & Cowan, 1992). Therefore, in order to capture the experience in question, the child was required to be under the age of three years. How couples became parents was not specified but included one or more of the following: drug therapy, in-vitro fertilization, or a spontaneously occurring pregnancy. Previously infertile couples that made the transition to first-time parenthood through adoption, donor insemination, or surrogacy were also excluded from the study as available research has suggested that the issues involved in these couples' paths to parenthood are often different from those who have a genetic link to their children (e.g. Levy-Schiff, Goldshmidt, & Har-Even, 1991). In addition, both members of each couple needed to agree to participate in one process I 46 interview, as well as a validation interview that was conducted after initial data analysis. Finally, as a basic requirement for participants in a phenomenological study is the ability to articulate the experience (Colaizzi, 1978), all couples articulated their story in English,' as the researcher was not conversant in any other language. It was estimated that six to eight volunteer couples would be needed for the study. As the intent of the study was a rich description of the phenomenon, data was to have been collected until it could be ascertained that the common themes extracted from the data, were not occurring by chance (Colaizzi, 1978). Recruitment was anticipated to cease when no new themes appeared to be emerging from the data. Recruitment Potential participants were recruited through advertisements placed at various locations within the Greater Vancouver Area, including parent drop-in centers, community centers, day-care centers, pediatricians offices, and libraries. With the assistance of a community health nurse, recruitment notices were brought to the attention of clients of the Vancouver Coastal Health Authority at Well-Baby Clinics and parent/toddler groups. In addition, the recruitment notice was posted electronically through a university mailing list, as well as through the Infertility Network, the Canadian national organization for those with a personal or professional interest in infertility. Individuals who were interested in participating in the study contacted the researcher by phone or email. Upon telephone contact, the researcher provided the prospective participants with additional information about the nature and goals of the study and the approximate time commitment involved. During this informal telephone interview, the potential participants were asked a series of screening questions to ensure \ 47 that they met the inclusion criteria. Participants were then given an opportunity to ask questions about the study and were fully informed of their right to withdraw from the study at any time. Arrangements for the first interview were made at this time, including the date, time, and location of the meeting. Ten potential participant couples contacted the researcher. Of the ten, only five met all of the inclusion criteria. Three couples were excluded from participating in the study due to being the parents of multiples, one couple was excluded due to having already given birth to their second child, and one couple was excluded due to one of the spouses' inability to meet for an interview. Finally, one of the five couples that met all of the inclusion criteria was excluded from the study as they lived out of province and the researcher was unable to travel for an interview. Despite the researcher's original desire to interview 6 - 8 couples, data collection was terminated after 4 interviews and approximately 6 months of recruitment efforts. The decision to terminate recruitment was made for both realistic and pragmatic reasons. First, the researcher had attempted recruitment by saturating the community with advertisements, targeting all areas that were likely to be frequented by parents of young children. No other logical options appeared to exist. Second, due to the researcher's own timeline for the study's completion, based on her personal and family needs, she could not wait indefinitely for potential participants. Data Collection Descriptions of lived experiences were collected through verbal accounts. The goal of the phenomenological interview was a rich description of the life-world of the interviewee that authentically reflected the phenomenon in question (Kvale, 1983; 48 Osborne, 1994). In order to allow for genuine experience to be conveyed, it was important that the research interview took place "in a situation of trust" (Colaizzi, 1978, p.69). Good rapport between the researcher and co-researcher, as well as the researcher's personal characteristics of authenticity, credibility, intuitiveness, sensitivity, and receptivity were essential to the dialogical relationship (Osborne; Rew, Bechtel, & Sapp, 1993), which was central to the interview process. In this study, two interviews were used to elicit detailed descriptions of the experience of making the transition to parenthood after infertility. Each interview was conducted with both members of the couple because it was believed that couple interviewing might lead to more trustworthy recollections by allowing the couple an opportunity to monitor and verify one another's description of the experience (LaRossa, 1983). The first interview was an in-depth, semi-structured, audio taped interview that lasted between one to two hours. The second interview was a validation interview conducted after the participants' descriptive accounts had been analyzed thematically. The principal researcher of the study conducted each interview. The initial interview took place at the homes of the participants and the second interview was done by telephone. A journal of the researcher's reaction to each interview was also kept. The first interview took place within one month of the initial telephone contact with potential participants. As good rapport was essential to the dialogical relationship (Osborne, 1990), the researcher eased into the interview by reviewing the nature, conditions, and parameters of the study. In accordance with informed consent, participants were reassured of their right to withdraw from the study at any time and were made fully aware of the study's confidentiality protocol. Each member of the couple was 49 asked to choose a pseudonym for the purpose of ensuring anonymity. Participants were also assured that the tapes of each interview would be erased or destroyed upon the study's completion. After this brief orientation, couples were invited to ask any question about the study that might have arisen since the initial contact. Participants were encouraged to seek clarification whenever necessary. Couples were then asked to read and sign two copies of an ethical consent form (see Appendix B). One copy was given to the participants for their records and the researcher retained the second copy. The participants were then invited to answer a series of demographic questions. The tape-recorder was turned on at this point. An orienting statement was utilized to initiate the conversation (see Appendix C), with tentative sample questions being available to deepen the exploration of themes as they were raised by participants (see Appendix D). The purpose of these minimally structured interviews was to allow the data to speak for itself (Osborne, 1990). The interviewer sought to use herself as a data collection instrument through the use of open-ended questions, active listening, and affective reflections (Rew et al., 1993). The researcher allowed the participants the freedom to share their story with little interruption and sought to avoid leading questions. An occasional probe was used only when necessary to solicit a more detailed description of the experience or to deepen exploration. Participants were encouraged to tell their story until it reached a logical end and the researcher only used prompts when they appeared to "run out of steam." After the participants had completed their thoughts, open-ended questions were used to elicit a more detailed account of the phenomenon. The interviewer also sought clarification or further elaboration on^  topics that appeared to be ambiguous or contradictory to the researcher. At the end of the interview, the 50 researcher specified a date by which she would contact the participants to make arrangements for the validation interview. After the researcher had left the interview, she wrote up her reactions to the interview. Once the participants' descriptive accounts were analyzed thematically, a validation interview was conducted with three of the four participants. One couple received the findings but was unavailable to participate in the final interview. Participants were asked to review and verify a short biographical description o f their experience as prepared by the researcher. This was to ensure that their account of making the transition to parenthood after infertility had been accurately portrayed. Participants were also asked to examine the common themes o f the experience of making the transition to parenthood after primary infertility and to comment on whether the findings accurately reflected their own lived experience. A n y new information resulting from the validation interview was taken into consideration in the final analysis. These interviews lasted approximately one half hour each. A t the end of each validation interview, as a preventative measure, the researcher f provided the participants with a list o f names and phone numbers of possible counselling professionals and support organizations, in case upon reflection of their experience, the participants felt that they required counselling support (see Appendix E) . Data Analysis Thematic Analysis Phenomenological thematic analysis is an interpretive process that requires considerable sensitivity. The meanings o f the verbal descriptions need to be interpreted by the researcher and the outcome w i l l depend on the researcher's perceptiveness in 51 relating to the data (Osborne, 1994). Osborne (1990) points out that the "phenomenological method is more of an orientation than a specific method" (p.83). The descriptive accounts can be analyzed in a variety of ways, however for my purposes I followed Colaizzi's (1978) seven step structured analysis. Prior to analysis, the tape-recorded interview was transcribed verbatim. Any of my journal notes were added at the end of the transcription. I first got a feel for the data by reading and rereading the couple's account of making the transition to parenthood after infertility. Once I acquired a general sense of the data, significant statements that directly related to the phenomenon were extracted from the interview protocol. I then sought to formulate meanings from each significant statement through an interpretive process Colaizzi (1978) refers to as "creative insight" where the researcher "must leap from what [the] subjects say to what they mean" (p.59). I took particular care to maintain a faithful connection to the participant's original description. These first three steps were then repeated for each interview protocol. The formulated meanings from each couple's account of making the transition to parenthood were then organized into common phenomenological themes across accounts. The clusters of themes extracted from the data were then compared with the original protocols to validate their accuracy. Procedures were re-examined and a new analysis was conducted when themes foreign to the original material were found. In accordance to Colaizzi's (1978) belief in the importance of tolerance for ambiguity, I noted any discrepancies among and/or between the clusters and held on to the idea that "what is logically inexplicable may be existentially real and valid" (p.61). 52 A n exhaustive description based on all findings was drafted. Finally, through a collaborative review with each participant couple, I sought to validate the findings. During a second interview, I asked the participants to read the descriptive results and to comment on how closely they reflected their own experience. Themes were adjusted, when necessary to better reflect the common experience of making the transition to parenthood after infertility. The purpose of these interviews was to determine the trustworthiness of the data. Limitations The results from this study are not generalizable to all couples that make the transition to parenthood after primary infertility. This is a limitation common to most qualitative studies, and reflects the typically small sample size and the fact that the participants had been purposely selected due to their unique qualities and not sampled randomly from the general population. In addition, the participants were self-selected volunteers, which likely biased the results due to specific characteristics held by those who tend to volunteer. The goal of this phenomenological research was not to explain but to describe an experience (Osborne, 1994). Despite the fact that this study cannot provide conclusive evidence, this exploration and description of human experience may inform practice and lead to further research and the development of theory. Another possible influence on the data in this study might be related to the qualities of the researcher. In phenomenological research, the investigator is considered to be the instrument (Rew et al., 1993). Osborne (1990) points out that, "phenomenological research requires that the researcher have personality characteristics and skills used by counsellors" (p. 88). Therefore, the trustworthiness of these results 53 depended in part on my ability to have continuously bracketed my presuppositions about parenting after infertility, my ability to have successfully built rapport with the participants, my attending and listening skills and on the level of my creative insight and interpretive ability. The relationship between the co-researchers and myself was critical to successfully illuminating the nature and meaning of participants' experience of making the transition to parenthood after infertility. Similarly, the participants' qualities might also have biased the data. As a self-report study, the information gleaned might or might not have reflected the participants' true experience. In addition, data might have been skewed due to the fact that the couples were interviewed together. Each member of the couple might not have felt as comfortable sharing certain aspects of their experience in front of their partner as they might have in a private session with the investigator. A final limitation in this study is that there was little demographic variation among the participants. The demographic characteristics of the majority of the co-researchers reflected those found in the infertility literature (e.g. Daniluk, 2 0 0 1 ; Gerrity, 2 0 0 1 ; Gibson & Myers, 2 0 0 0 ) : white, well-educated, middle-to upper class North Americans of European descent. This is the population that tends to seek infertility treatment. The lived experiences of previously infertile couples making the transition to parenthood who do not have the financial resources to pursue medical treatment or who are from another cultural background might be notably different. 54 Chapter Four ~' FINDINGS Introduction This chapter contains the bio-synopses of the four couples that participated in this study. These are brief summaries that provide demographic information and describe the couples' history of infertility, their pregnancy, and their transition to parenthood. Following the bio-synopses are the five themes that emerged from an analysis of the couples' interviews. The meaning of each theme is described and supported by quotes from the couples. Couple Bio-synopses Couple One - Chrys and Nabil Chrys and Nabil have been married for nine years and are 35 and 3 4 years old respectively. Chrys is originally from Greece and Nabil from Lebanon. Both have university degrees, work together as physiotherapists in a self-run business, and are within the upper middle-income bracket. Chrys and Nabil spent four years trying to conceive before becoming pregnant. Their daughter is now almost twenty-one months -old. Once it became clear to them that there may be a problem with their fertility, Chrys and Nabil began to undergo testing. After some time it was discovered that Chrys had endometriosis. The couple began IVF treatment and after the fourth failed attempt conceived. Two and a half months into the pregnancy, after mixing up test results, their doctor informed Chrys and Nabil that they had miscarried. However, during an 55 ultrasound prior to a .scheduled D & C, a strong heartbeat was found and the error discovered. Chrys describes her pregnancy experience as "the best part." She believes that after all the stress of infertility and the scare of miscarriage that "God made it up to [her] with a great pregnancy." She loved being pregnant and loved the way her body worked. After the initial scare, there were no complications during the pregnancy or birth. Chrys and Nabil describe their infertility experience as a very vulnerable emotional time where they existed in "some sort of limbo." At the time of conception, Chrys and Nabil were making arrangements to close their business and leave the country in search of better fertility treatment. For the first two years they grappled with their infertility alone, keeping their struggles private from their families. However, as time went on and as other members of their family became parents, they decided to be open about their difficulties. Chrys and Nabil describe their openness as being both helpful and problematic. On one hand they appreciated the support and prayers they received from family members but found the advice to "just relax" only added to their stress. Some members of the family refer to their child as a 'Miracle Baby' but Chrys and Nabil do not share this view. They believe that all children are miracles regardless of how they enter the world. They do not see their child as "more special" than any other child nor do they think that they would have treated their daughter any differently i f she had arrived four years earlier. However, because their daughter came after so many years, they feel "more blessed." They do not take her for granted and appreciate all that they have in life. 56 When asked to describe their experience of becoming parents after infertility in terms of a metaphor, Chrys stated that it is like a "second chance to life." Nabil describes his experience as being like "getting out of a cage." Couple Two - Susan and Chris Susan is a 32-year-old Caucasian woman and Chris a 3 5-year-old Caucasian man. They have been married for six years and are the parents of a six-month-old son. Susan and Chris were involuntarily childless for 5 years before conceiving their son. Both members of this couple are college educated. The current household income is within the middle-income range. Susan is not working outside the home at present. Six months to a year after their marriage, Susan became pregnant. However, two months later she experienced a miscarriage. Despite the sadness of losing the baby, Susan felt somewhat relieved that she could get pregnant. At this time her older sister was undergoing an assortment of treatments for infertility and Susan was intimately aware of the struggle involved. < Three months after the miscarriage, Susan and Chris began trying to conceive again. After almost a year of trying without success their family doctor sent them for tests. It was discovered that Chris had malformed sperm caused by, what was thought to be, an overgrown vein on one of his testicles. Chris underwent corrective surgery and six months later was retested. The results were worse than before the surgery. At this point their doctor referred the couple to a fertility clinic. This was a very stressful time for Susan and Chris. Susan describes herself as feeling "quite depressed about it." To make matters worse, the couple found their experience with the fertility clinic to be very negative. They felt like they were "buying a used car" and were turned off by what they describe to be a "heavy sales pitch." Due to 57 their discomfort with the fertility clinic and Susan's uncertainty as to whether she could go through treatment without any guarantee of a child, they decided to forego fertility treatment and instead committed themselves to a holistic healing center for one year. The individualized treatment plan included items such as exercise, nutrition, massage therapy, and acupuncture. Chris was especially dedicated because he noticed that he felt healthier overall. Almost one year to the day they started at the center, Susan was pregnant. Susan describes the pregnancy as being pretty much problem-free, although she did experience some heightened anxiety at both the beginning and end of her pregnancy. During the first trimester, Susan was fearful she might miscarry again and was given an ultrasound to ensure that everything was all right. She also waited four months before telling co-workers she was expecting for fear of having to explain a miscarriage. At the end of the pregnancy labour was induced without success and Susan delivered by C-section. She described feeling very frightened that, after waiting for so long, something would go wrong. Despite giving birth to a very healthy baby, Susan still experiences a lingering fear, which she refers to as 'paranoia,' that something might happen to him. Chris does not appear to share this fear. While Susan and Chris would like to have had a child without going through the stress of infertility, they believe that the experience has changed them in a positive way. Susan stated that "[they] needed to go through something as couple." Both Susan and Chris described feeling really ready for parenthood and feeling very lucky to have their son. Most notably, this couple appeared to be keenly aware of the joy their son brings to their life. They believe that they might actually have a happier baby because their own 58 enthusiasm and happiness to finally have him "nibs off on him" making him "naturally happy." Due to the difficulties having their child, Susan and Chris appear to see their son as extra special and consequently feel a greater sense of responsibility to raise a happy child and a good person. Couple Three - Stephanie and Todd Stephanie and Todd have been together for eleven years and married over six. They are Caucasian Canadians and are 34 and 41 years old respectively. Both Stephanie and Todd hold graduate degrees and have a combined family income of over $75,000. Stephanie is on maternity leave from her work and Todd's employment allows him to be home for varying lengths of time. This couple spent three years trying to conceive before becoming pregnant with their now six-month-old daughter. For Stephanie, having children was never a question. She loves children, children love her and she knew that someday she would like to have her own. Todd, on the other hand had not always been as certain about becoming a parent. However, before they married he came to the decision that he too would like a child. Stephanie and Todd were very purposeful in their decision-making to have a child. One year before they thought they would like to become pregnant Stephanie went off the Pil l to give herself "one year clear" and to "get it out of [her] system." They used other control methods until they were ready to start trying to conceive. Stephanie reflected that it was a bit shocking that after a few months of unprotected sex, pregnancy did not occur. After about 8 months, Stephanie and Todd mentioned their difficulties to their doctor and then began some lower level interventions through a fertility clinic. 59 During the three years of unexplained infertility, Stephanie and Todd actively pursued answers to their childlessness through research, by asking questions, and changing clinics. They were very invested in the process both physically and psychologically. However, as time went on and as the level of treatment became more "intrusive" and "more costly, " Stephanie began to experience some doubt as to whether treatment would be effective. Todd did not share these doubts. He felt what he describes to have been "blind faith" that when they had a chance to try IVF, it would be successful. Stephanie was aware of the cost, effort, and timing involved in IVF and knew that she "couldn't go through the process a lot of times in the end" so began to prepare herself for living childfree. Happily, Stephanie did not need to make this adjustment as she became pregnant after her first IVF treatment cycle. Stephanie describes becoming a parent as being "a very natural process." After so many years of waiting and being "really ready for parenthood," any challenges of parenting seem to be taken in stride. However, both Stephanie and Todd expressed that they were somewhat surprised by the amount of love they feel for their child, a love which Stephanie describes to be "wondrous." A notable aspect of the interview with Stephanie and Todd is the clear sense they had of themselves as partners. This was certainly reflected in their ability to communicate their thoughts and feelings openly with one another. Todd and Stephanie were also aware and appreciative of the fact that, due to the flexibility of Todd's work schedule, he is able to participate more than other parents who work a 9 to 5 job. For Todd, the experience of infertility appears to be over. He stated that it is not something he normally thinks about. However, it is different for Stephanie. She thinks 60 J about their fertility issues when she thinks about having another child. She thinks about the embryos in storage at the fertility clinic and their potential to grow into a child that they will love. She stated that she does not want to "abandon them" and views parenthood as not only involving their daughter but also the decision of whether or not to have another child. When asked to describe their experience of parenthood after infertility, Todd stated it was like being in the sunshine after having been stuck in the clouds. Couple Four - Christine and Paul Christine and Paul have been married for nine years and are the parents of a 14-month-old son. Christine is Canadian and holds a Masters degree. Paul is British and has earned an International Diploma. Their combined family income puts them within the middle-income bracket. Christine, now 37 years old and Paul, 36, spent three years trying to conceive. For Christine and Paul, the process of infertility appears to have been particularly grueling. Paul refers to the three-year period as "definitely the hardest thing [he'd] ever experienced in [his] life." Christine refers to their infertility as "really stressful and really hard on [their] relationship." Judging from their story, Christine and Paul's road to parenthood appears to have been littered with numerous negative and highly stressful events. After one year of unprotected sex, Christine and Paul were referred to a fertility -specialist who they felt did not take their concerns seriously. They requested a test to see i f Christine had endometriosis but were denied one. The doctor had Christine do a few cycles of drug therapy and suggested that they go home and keep trying. Paul was not in 61 agreement about going back to the fertility clinic but supported Christine in her decision to do so. Christine ended up doing two cycles of intra-uterine insemination. Christine spent a lot of time researching infertility on the Internet and chatting with other women who shared her experience. On occasion Christine would meet with women in a local group for lunch. One lady told Christine about a naturopath, which turned out to be "the best thing that [they] ever did." Within three months Christine and Paul were pregnant. Sadly, this pregnancy was ectopic and had to be terminated. Paul refers to this as being a "sad, sad time." However, despite the difficulty of the situation and the enormous disappointment, Christine felt some happiness because she knew that she could at least get pregnant. During the termination, endometriosis was found covering Christine's tubes and inhibiting the fertilized egg from traveling to the uterus. Once the endometriosis was removed, Christine and Paul got pregnant right away. While Christine and Paul attribute much of their success to deciding to leave the fertility clinic and seeking treatment with a naturopath, Paul describes a series of events that helped to create a "positive redirection in [their] efforts to conceive a child." Christine stopped spending time on the Internet, which she recognized only added stress to the situation. They changed their diet and Christine took up yoga. The couple also decided to seek counselling to help with "the strains and stresses that had cropped up along the way." Both Christine and Paul found the counselling to be very helpful. The desire for a biological child was particularly salient for Christine who had, herself, been adopted as a child. She stated that she "really wanted to have some kind of physical connection with someone." She remembered thinking as a young adult that the very worse thing that could happen to her would be i f she was unable to have a child. 62 Christine's inability to conceive was very difficult for her. She stated that she became "obsessed with it" and isolated herself from other people. Paul described Christine as "barely existing" during that time. He found it very difficult to see Christine so unhappy. During Christine and Paul's pursuit of parenthood they attended an adoption seminar, which they found to be another negative experience. Christine and Paul had always thought that they would like to adopt in addition to having a biological child. The agency promoted open adoption and had birth mothers in attendance to testify to the importance of having contact with the child. Christine, who had chosen not to seek contact with her birth parents, was singled out and used as an example in the group. Christine and Paul realized that the agency was not a good fit for them. With these hurdles behind them Paul described the pregnancy as a "delightful time." There were no real worries; it was just a happy time. Christine described the experience of becoming pregnant as almost erasing the time of infertility, that "it was almost as i f instantly the infertility hurt just went out the window." While Paul really enjoyed the pregnancy, he still harbored some concern that "something would come and foul things up." Christine, on the other hand, "never felt there was going to be any problem." Christine's pregnancy went along without complication until delivery. During labour, the placenta began to detach. Christine ended up losing a lot of blood, which precipitated an emergency C-section. The first few months with their new son was pretty grueling with Christine recovering from the birth and having an undiagnosed case of mastitis that took weeks to clear up. Despite these difficulties however, she described the pain of birth as being "not an inch.. .nothing compared to the pain of infertility." 63 Christine described their son as a "beautiful gift" and Paul has found becoming a parent to be "like breathing." When asked what their greatest gain has been for them individually and a couple, they both identified their son because he is "amazing." It was clear that both Christine and Paul delight in their child. The experience of infertility does not appear to be over for this couple, however. Christine and Paul want another child and have some concern that conception may not occur easily. Christine expressed a very real fear of "going back down that slope again." This trepidation is not surprising given the intensity of their struggle with infertility. When asked to describe their experience of becoming parents after infertility Christine stated it was kind of like "flicking off all the dead energy." Paul described it to be like "getting out of jai l" where there is "freedom of all the chemicals, and drugs, and procedures, and prodding, and poking, and tests, and all that kind of business." Both Christine and Paul also described the experience as "starting life again." Identified Themes Through detailed analysis of the in-depth interviews as described in Chapter Three, five themes emerged that were common to the couples in this study. In no specific order, the five themes are as follows: 1. A Sense of Gratitude/Being Blessed j 2. A Sense of Appreciation/Not Taking Parenthood for Granted 3. A Sense of Completion/New Connection 4. A Sense of Readiness/Purposefulness 5. A Sense of Parenthood as a Positive, Healing Experience 64 A Sense of Gratitude/Being Blessed Both members of each couple unanimously expressed an almost indescribable joy at becoming parents after having struggled with their fertility. Underlying this joy there appeared to be a clear sense of gratefulness for their child and their role as parents, as well as, a sense of being "blessed" with the "gift" of their child. Three of the four couples even acknowledged that on some level they were grateful for the experience of infertility itself, in terms of their growth as a couple and "lessons learned." Although a few of the parents in this study spoke of having felt optimistic that "it would all work out in the end," the majority believed that never becoming parents to a child biologically connected to them was a very real possibility. With each failed attempt to conceive, these couples experienced a loss and became even more keenly aware of their desire to have a child. The road to parenthood for these couples tended to be long and arduous and for some, to finally become parents, was almost "unbelievable." One mother, whose journey to parenthood had been particularly challenging, made this comment: "It's good. Every night before I go to bed, well most nights, we'll go in and look at him and [we] just can't believe he's there." Another mother expressed her joy and wonder at finally becoming a parent in terms of her good fortune saying: "I guess I never would have thought I would have this life. Like I just feel lucky, you know? Really lucky." This sentiment was reiterated in the words of a father who stated: "So suddenly it was like, 'wow!' And we finally arrived. We felt so lucky to have him, you know?" For these individuals, to become parents after many years of infertility was something to marvel at and filled them with a strong sense of gratitude. 65 Several couples described their experience of becoming parents in terms of being "blessed" with a "gift;" the gift of a child and the gift of parenthood. One mother in reflecting on the pain of infertility stated that, "God made it up to [her] with a great pregnancy." While all of the mothers in this study could not attest to "superior" pregnancies, it was clear that this mother felt that her struggle had been rewarded to some degree. For three of the four couples, their overall attitude was not that they had triumphed over adversity or had secured a victory over infertility but rather that, "after all was said and done," they had been "given" the very gift their hearts desired, one which they had believed they might never receive. The essence of their words seemed to portray the belief that they were not in charge of their fertility and that luck, fate, or a power beyond themselves had a hand in their becoming parents. For example, one mother reflected that while she was going through the process of fertility treatment she became an aunt for the first time. She saw this child as a miracle and "God's gift to her parents" and she thought to herself that, "God gives gifts, He will give to me [too]." Both she and her husband stated that when they finally became parents, they felt very "blessed." For the majority of the couples in this study, feeling "blessed" or full of gratitude for the gift of their child was an ongoing experience. One couple observed that their thankfulness for their daughter had continued to grow as she grew and developed and changed. The mother enthusiastically described her gratitude and wonder in the following way: 66 Especially, at every time she is going through a phase, which is so great. And you go, 'ok 3 days old, she is so sweet. One week old, one month old, now she can sit, now she can crawl, now she can walk, now she talks, now she is discovering this... 'And every single day of her life which is every single day of our life is just something beautiful, something new. It's like a little gift every day, which is just incredible. It is incredible. I mean we knew we wanted her but we, that we just...yeah... This couples' child was the oldest at the time the study began. It was apparent that their joy in their child had grown over the months and that''they expected their feelings would continue to deepen over time. Another couple expressed a similar sentiment when they described the love that they felt for their daughter: We probably didn't know the amount of love that we would feel. I mean it did surprise me, I mean it struck me when, very early on that I thought, you know, I love her so much today there is no possible way that I could love her more and the next day I loved her more. I thought, 'Boy my heart's not going to fit in my body by the time she's two years old because it's going to be too big!' I mean it's wondrous. But I sort of expected that but it's, it's an experience. I sort of expected the experience but I didn't know what the experience was going to feel like, you know, the essence of it. This couple's description of the love they felt for their daughter reflected an awareness of how fortunate they were to have the chance to love their child. 67 The couples in this study made it clear that they did not believe that their love for their child was any deeper than it would have been if their child had come without having had experienced infertility. One father summed up his feelings this way: I don't see my daughter any different. I don't think I would have treated my daughter any different i f she was conceived four years ago as opposed to.. .whether we were infertile or not. I don't think that's an issue. The fact that she came after all these years I might feel more blessed now than maybe I would have felt i f we had conceived her less than 5 years ago. This father believed that his experience of parenting his daughter would not have been very much different i f she had arrived without a struggle with infertility; however, he recognized that his sense of gratitude for his child was likely more deeply felt due to that experience. Overall it appeared that the couples in this study seemed to be acutely aware of the value and meaning their child had in their life and were thankful. The gratitude that these couples expressed having for their child and their role as parents also extended to the experience of infertility for three of the four couples in terms of their relationship with one another, their health, and feeling prepared for parenthood. One woman, who had had a miscarriage early in her marriage, reflected on their readiness to make the transition to parenthood: I think it was fate too. When we look back at the first pregnancy and i f we'd have had that baby then, I don't think we would have felt the same way we do now, you know what I mean? Like I just don't think we were ready then. We needed to go through something. I don't know.. .as a couple maybe... r 68 This couple felt their experience of infertility provided them with a valuable opportunity to grow together as a couple. One couple that had sought counselling to help them cope with the emotional consequences of infertility described their experience as having been useful to them in their lives. Despite the profound difficulties they had experienced during their infertility, they were, in some ways, thankful for the experience. The wife, with some amazement at her own words, stated that: Three years ago I never would believe that I could say this but sometimes I think it was a good thing because of our relationship as wellas my health. I didn't know I had endometriosis and that can lead to cancer and other kinds of stuff, you know? So I do feel.. .grateful almost.. .which is bizarre. Her husband agreed and said, "We learned something. Which has been good for our lives in many ways." Not only did this couple learn something about their relationship, they gained valuable and important information about the wife's health that they might not have discovered otherwise. Finally, one other husband considered a practical aspect of infertility in terms of it providing he and his partner time to prepare for parenthood, which ultimately aided in their making the transition with some ease. He commented that: The time where we were trying but not being successful through our infertility, did give us time to research parenthood quite a bit . . . That's got to be the only silver lining! It gives you time to bone up and read what you need in terms of what you should expect when you become a parent. 69, This husband, however, quickly clarified his position on the benefits of infertility when he said: But having said that.. .like I say it's the only silver lining. I'd trade jumping in with a baptism by fire, you know, being a little unprepared over the experience for sure. But I think that's probably obvious.. .nobody would choose otherwise. The couples in this study would have preferred to become pregnant without the stresses and strains of infertility. However, three of the four couples reflected that their journey to parenthood might have enriched their lives in ways for which they are grateful. In summary, the couples in this study conveyed an almost inexpressible joy at becoming parents after having struggled with their fertility for many years. Couples felt "lucky," "blessed," and "very grateful." The couples appeared to cherish their child as one would a special gift. However, when asked to consider the impact infertility had had on their transition to parenthood, the majority of the couples felt that their experience was not much different from parents without fertility issues in terms of their relationships with their child. They doubted that they would have treated their child any differently i f he or she had arrived earlier. They did however seem to feel that they had gained in terms of their marriages, readiness for parenthood, and their gratitude of being able to achieve that role. A Sense of Appreciation/Not Taking Parenthood for Granted The couples in this study expressed a sense of appreciation for their child and their role as parents and stated that they did not take either for granted. These couples felt the experience of desiring a child and not being able to have one made them 1 exceptionally aware of their child's importance, value, and meaning in their lives. The 70 parents even attributed their ability to cope with the stresses and strains of parenthood better than they might otherwise have, on their level of appreciation for their child. For the women, in particular, listening to the complaints of fertile counterparts appeared to generate much frustration. They were to some extent bothered by the fact that some fertile women did not appreciate how very lucky there were to be mothers. One woman in this study stated that she was well aware of the fact that she may have difficulties conceiving due to having watched her older sister struggle with infertility for many years. However, the other women in this study suggested that they had initially taken their fertility for granted. One mother who had decided to go off the Pil l for one year prior to trying to conceive in order to get her body "prepped and ready and fine" for pregnancy stated that: It was a bit shocking for me that with a couple months of unprotected sex pregnancy didn't resolve! Because all your life, all my life, I had been told you do it once and that's it. So you grow up as an adolescent, as a teenage girl, scared that you'll get pregnant at every opportunity... This couple, like others in the study, had been very deliberate in their decision-making process to begin a family, taking into consideration their ideal timing and "never thinking that there was going to be any sort of a problem." Another mother commented not only on her personal expectation of parenthood but of what she felt was expected of her by society. She said: ' There's a stigma, I guess about people not being able to have.. .you're supposed to have so many cars, so many houses, so many children, whatever. But it's taken for granted that you can have a child... I 71 As reflected in the words of these two women, the couples in this study did not anticipate having difficulties conceiving a child. Consequently, their infertility was an unexpected and very challenging life event. One couple, who had been conscious of the fact that some people have difficulties conceiving, had discussed the level of medical intervention they'd be willing to undergo if it was ever necessary for them. The wife described how their opinion changed when actually faced with IVF when they were unable to produce a child: Before we were trying we obviously discussed about some people having fertility problems and how far, i f it ever happened to us, which we never thought it would, how far we would go. We never thought we'd go as far as IVF...maybe because we took [our fertility] for granted too. So.. .then once we wanted her and couldn't have her we realized how important it was... This couple said they really didn't believe they would ever need to make tough decisions about fertility treatments and were surprised at the extent to which they were eventually willing to go in their efforts to become parents. Not only had they taken their fertility for granted but also they had underestimated the ease with which they believed their fertility decisions could be made. Because these couples had to go through so much to have a child, including making difficult decisions about fertility treatments, they reported feeling "really lucky that things worked out in the end." One father eloquently described his and his wife's experience of becoming parents after infertility this way: 72 But you know what? We've never experienced the other, you know, just deciding to have kids and having it being easy. So we don't know what that's like. But I think we really looked forward to it and really valued that [our son] made it. This couple, as was the case with the other couples in this study, really appreciated becoming parents - an appreciation that was heightened by their fertility struggles. This may also explain why several of the couples commented on the fact that they don't take their child, or parenthood, for granted. This attitude appeared to help the couples deal with some of the more stressful aspects of parenting a small child. For example, one couple spoke about the challenge of sleepless nights and the lack of time that they had for one another as a couple. However, the mother remarked: I feel that.. .because we had to go through such a lot to get to have our own child, I don't know.. .maybe it helps you deal with some of the tougher moments with no...resentment. Another mother expressed a similar sentiment: I think you don't take as much for granted, you know, like I think I have more patience than I would have otherwise. Later in the interview this same mother stated that she tries not to complain about being tired or about having a difficult day with her son, because she "waited so long to have him," that she doesn't "want to start complaining about him." Perhaps also related to their infertility struggles and subsequent appreciation of finally becoming mothers themselves, three of the four women in this study commented on how they had little tolerance for the complaints of other mothers regarding their 73 children and/or the demands of parenting. One mother described her reaction to some of the women in her prenatal group: Some of them were just complaining the whole time and not really seeing the joy in it. Well I, you know, I was sick and stuff but I wasn't that way. I don't know, I think I appreciated it more. This mother felt that the women who had no difficulty becoming pregnant did not appreciate the significance of being able to conceive and felt this fact set her apart from the group. Similarly, another mother in this study described her lack of connection to other new mothers when she stated that: I don't know, maybe I just don't feel the connection to other women because of the whole infertility thing.. .sometimes.. .because I feel like they were so lucky... and because it took us that much longer it's just not the same thing. Like the things they complain about and stuff like that. I'm like, you know, 'why are you complaining about something stupid like that? You know, you're so lucky to have kids.' I still feel like that, even though I used to feel even worse like that when I didn't have kids of my own. As was the case for the other couples in this study, this mother believed that what set her apart from other parents was her level of appreciation for parenthood and her determination to not take it, or her child, for granted. According to some of the couples, the sense of appreciation and not taking things for granted extended beyond their "child" and their "parental role." Participants in this 74 study felt that becoming parents after having experienced infertility gave them a new outlook on their lives. This perspective was captured in one father's comment: I feel that I'm so much more content, that a lot of things don't matter anymore. Things that I would worry about before, whether it's for work or for anything.. .they just don't matter anymore. Because at one time, you know, when [the baby] was not born yet and we, we were not, we didn't conceive at the time, we were saying, you know, 'what are we doing here?' Like you know, you worry about so many things in your life and I ' l l say to myself, 'If I would have one child, I wouldn't worry about anything else anymore.' And it's true, I really don't much anymore, I'm a lot more easy about everything. If things don't work out that's fine so to me this is the most important thing and yeah I feel just because we have her nothing else matters. The opportunity to become parents seemed to result in a "putting into perspective" and "prioritizing" for these couples. In summary, these parents, after waiting for so long to conceive, expressed a strong sense of appreciation for their child. They were keenly aware of the importance of their child in their lives, individually and as a couple, and were cognizant of the difference their child's presence has made in their lives. These couples attributed their relative ease in making the transition to parenthood to the fact that they do not take their child, or their role as parents, for granted. They believed their appreciation for their child and for the opportunity to become parents provided them with a perspective that allowed for "patience," "tolerance," and "little resentment" when dealing with the strains of parenting. 75 A Sense of Completion/New Connection For the couples in this study, the arrival of a long-awaited child brought to the fore a sense of completion and new connection. Couples tended to feel more connected to one another, and to their extended family since becoming parents. Couples also expressed feeling more "whole" in terms of themselves as individuals, as a family, and as part of a natural process of life. Several parents commented that since the birth of their child they "[felt] more like a family now. Not just a couple." One set of parents described their child as being the one missing link in an otherwise satisfying relationship: Father: I think we both do feel more complete as a family. Mother: And there was something missing and now we have it... Father: It was something that, something we wanted. I mean we had a very good relationship as a couple but we always wanted to have a child so it's something that [has made] us complete:. This couple, despite a fulfilling relationship, did not feel like a "family unit" until the birth of their child. This sentiment was shared by several of the parents. Couples also spoke of experiencing a new connection with their spouse after becoming parents, which they felt had positively impacted their relationship. For example, one mother stated that a change in her relationship with her husband took place after she became pregnant. She described it this way: I think [becoming parents after infertility] has impacted our relationship too. That whole nine months or when I was pregnant.. .1 think we got closer then I think we 76 ever had been, you know what I mean? A n d then we had [the baby], it was like, you know, this different atmosphere, kind o f thing. Once they had overcome their infertility, the change in this couple's relationship seemed to happen immediately. Other couples described a new connection to one another after becoming parents. One mother commented on a renewed bond in terms o f an appreciation of her spouse as a parent to their child: But then, it also.. .we have new dimensions to our relationship in terms of how much I appreciate and value [my husband] as a wonderful dad. For this mother, seeing her husband interact and love their child added a depth to their union, and a greater appreciation for him as a partner based on how he filled his role as a parent to their child. Some parents explained their sense of new connection in terms of partnership and commitment. For example, one father stated that, " A s a couple we've always had a strong sense o f partnership between us [but the baby] added a layer of depth and significance to that partnership." Another father similarly spoke of a renewed commitment to his and his wife's partnership since making the transition to parenthood. He explained: In terms of the biggest gain is that it has deepened my sense of commitment. Unexpectedly deepened my sense o f commitment to our partnership.. .It was surprising and unexpected.. .1 mean I didn't think, again you know that I could love [my wife] any more I do. A n d my commitment to our partnership i s . . . deeper. 77 For these couples then, the birth of a child after many years of infertility provided them with a sense of completion as a family unit and with a deeper sense o f a connection to one another. Three o f the four couples expressed a renewed connection to their extended family as well since becoming parents, although for one couple, this was not the case. Nonetheless, one mother stated, "I want to be around family a lot more than I ever used to be." This mother had just come back from a visit to her husband's family and was overjoyed by the mutually positive response her in-laws and her child had to one another. Her husband similarly described his experience: I suddenly realized, the past little while, how important a family is and being closer to the family, our families and stuff like that. Y o u know it is definitely a new connection. In the past, this couple had been somewhat isolated from their families since they did not live in the same part of the country. However, now that they were parents themselves they spoke o f a new desire to make an effort to visit their families more often than they had in the past, and of having a greater appreciation of the importance o f extended family involvement in their lives and in the life o f their child. Another father, whose extended family lives in another country, stated that although he does not see his family often, he feels more connected to them now that he has become a parent. He commented: [I am closer to my family now] in some ways because I've seen them all have children and I haven't really.. .1 could never really relate to them.. .so.. .yeah. I can relate to them more so now. It's probably brought me a little bit closer now 78 but I see them as infrequently and speak to them as infrequently but I can, I can relate to them.. .what their experience is.. .a shared experience. For three of the four couples in this study, the birth of their child allowed them to either reconnect or connect in a new way with other family members. Another common experience of the parents in this study was. the sense of feeling more complete as a person and as a member of society. One mother stated that she now "[felt] more like a normal person than.. .a not normal person." In a society that values children this woman did not feel like a "real" person until she had had a child. The couples in this study longed to play the role of parent and felt incomplete when they were unable to do so. A s one mother said, "We did feel something was missing, not in the relationship but individually, something missing out of an individual's life. So I, yeah definitely [feel] more complete." This mother believed that she and her husband were meant to have the role of "mother" and "father" and reported a sense of completion as individual people, after becoming parents. For one woman in this study, becoming a mother was not only fulfillment of a role but of a journey that she always believed she was meant to take. She not only desired a child, she believed that she was destined to be a mother. She described it this way: I think.. .finally I have my own [child]. I know.. .there's been some part of me, I just know I've always supposed to have been a mom. Not only a mom but that part of my life was, is, to be a mom and to learn how to be a great mom. And so, to me it's like I'm starting to fulfill one of the paths, one of the journeys that I 79 always dreamed of and thought I would travel. So there's a great deal of excitement and pride and I'm just relishing the opportunity to do that. This woman had spoken about her desire to become a mother as being a very "natural process." She had babysat as a young girl and had always had many "little friends" and children in her life so becoming a mother herself finally was an "opportunity to have her own" and to fulfill one of her dreams. > In summary, becoming parents for the couples in this study provided them with a sense of completion and new connection. While each of the couples expressed that they had been happy in their relationship with their spouse before the birth of their child, becoming parents made them feel more complete as people, and as a family. For some, the achievement of parenthood meant that they were on the path they believed they were meant to follow. For others, it simply meant that they had finally "arrived" and that the "natural order of things" was continuing. Becoming parents also gave these couples a sense of new connection to their extended family and to each other. The couples stated that they had experienced a new level or dimension to their marital relationship, one that they appeared to value very much. The couples also appeared to appreciate and value their renewed relationships with extended family members. A Sense of Readiness/Purposefulness Three of the four couples in this study spoke about feeling very ready for parenthood by the time they finally made this transition. The remaining couple, however, had not thought about parenthood beyond their ability and desire to conceive. The three couples, for which this theme is relevant, described feeling that their experience was different from other parents because parenthood hadn't come easily. The participants •1 80 reflected on how, throughout the process of infertility, they had to question and recommit to parenthood repeatedly. Consequently, their decision to become parents was very purposeful. In this regard one father described their experience of becoming parents as being very different from their fertile friends and family members: It was a roller-coaster ride, you know, just the emotions and stuff so.. .you don't like going through it.. .but I think it changed us too. Yeah it's not just like, 'ok we're going to have kids... ' you have a decision and it's like, flick a switch here's a kid, you know? If wasn't like that.. .so it was.. .1 think it was probably different that way. Another parent similarly described: So I think parenthood is no accident.. .we haven't fallen into parenthood, we've actively chosen it. It went from being prepared and waiting for it to happen, to actively saying, 'ok, we're going to do something about this.'... So I think that in the process of sorting out the fertility issues, we were just much more aware and much more present in the decision-making process of what.. .how far to go, how long to try. These couples had to question and recommit to their pursuit of parenthood time and again. At each stage in the process of dealing with their infertility, these couples had to make the decision to actively pursue parenthood. As such, becoming parents was a very deliberate and purposeful act in their lives. The couples in this study had between three and five years from the time they decided to pursue a pregnancy to become accustomed to the idea of parenthood. Their 81 reproductive quest allowed them time to think about, and prepare for, parenthood. As one woman commented: So I think it's just a much more aware process, much more deliberate and in the end when the pregnancy occurred.. .just a real readiness for it. Like, we're ready, we're not caught unprepared, this is no surprise, this is what we want and we're thrilled. Reflecting the sentiments of all the participants, one woman simply stated: "We were ready.. .It finally came and we were ready.. .ready for the pregnancy and ready for a baby." One apparent positive outcome of being ready for parenthood was a perceived ability to deal more effectively with the challenges of parenting a newborn. One mother commented that she had been so ready for parenthood that any of the challenges were just taken in stride. Another apparent benefit of having to wait to become and having to repeatedly rethink and recommit to the importance of parenthood in their lives was that these couples had an opportunity to consider what kind of parent they would like to be. As one father commented: As for adjusting to parenthood, when we first set out and decided we were going to have kids I still.. .although I always wanted to have kids, I was just still concerned about things like money and are we ready and all that kind of stuff.. .but then we went those 4 or 5 years without anything, nothing.. .and by the time [my wife] did get pregnant I was kind of in the mind set that it didn't matter, timing didn't matter anymore. It didn't matter i f we, weren't ready financially and things like that. Just having [the baby] was more important, you know? And also 82 I think after all those years too, I was definitely ready to have a baby so the concern shifted to actually.. .what am I going to be like as a parent? ... So I was really looking forward to it. As with the other participants for this father, a sure sense of readiness gave him the freedom to consider how he would like to be as a parent. His focus changed from being ready financially to being ready personally. In summary, the majority of couples in this study expressed a clear sense of readiness to embark on the transition to parenthood. This appeared to be due in part to the length of time it took to become parents. More apparent, however, was the fact that these couples were required to question and recommit to parenthood with each and every treatment decision they made. Their pursuit of parenthood was very purposeful. A Sense of Parenthood as a Positive, Healing Experience For the couples in this study, parenthood was experienced, for the most part, as a positive healing experience. Overall, the couples reported being able to put their infertility experiences aside. This was due in part to a decrease in stress and a sense that the pain of infertility had been healed. The couples generally felt that their experience of parenthood was the same as any other parent, regardless of their fertility issues. However, the couples acknowledged a high level of anxiety at the beginning stages of their pregnancy, a feeling of being set apart from other parents due to having had a different "pregnancy story," and a lingering awareness of their infertility especially when considering a second child. The stress and pain of the infertility experience dramatically decreased for some couples at the point of conception. As one mother stated: 83 When we had the positive result and I was pregnant, I think from that moment.. .1 mean we were just so happy and finally we were going to be parents.. .it had been.. .it [was] a long process. Another mother expressed a similar view: It was almost as i f instantly the infertility hurt just went out the window. And we never really thought about it again.. .that whole time. These couples experienced the joy over their impending arrival as therapeutic in itself. In sharp contrast to their infertility experiences the women delighted in the knowledge that their "bodies were doing what they were made to do." For example, one mother's opinion about her body changed dramatically during her pregnancy. She said: I loved the way my body worked. I hated my body before. But [during my pregnancy] I loved it. It was perfect, it was beautiful, it was perfect. This woman had been diagnosed with endometriosis and at the point of conception had been discussing with her doctor the likelihood of never conceiving. She had felt frustration and anger with her body prior to becoming pregnant. One father described the pregnancy as being "just a really happy time." He marveled at the fact that they had somehow overcome their infertility. He reflected: It was pretty amazing to actually.. .at the end of.. .the beginning of the end.. .it felt miraculous that this had actually occurred and we had somehow triumphed over this.. .dark, dark era and unhappy, unhappy time of ours. This couple talked about experiencing an enormous amount of stress and sadness during their struggle with infertility. The pregnancy did not wipe away all of their pain but it was the beginning of their healing. 84 Several couples spoke of the joy and happiness they now experience having finally become parents. As one father shared: There are more of a lot of happier [times], you know since [the baby] arrived. Just everyday I'm excited.. .you know? It's still new.. .but.. .you know it's exciting. Life has changed for this father. The unhappiness that he and his wife experienced throughout their pursuit of parenthood, no longer exists. They are now excited about their life. Another couple discussed feeling far more contented. The father stated that he feels "a lot more calm" and that the "stress is less than it was before." He also remarked that, "life is perfect now and [that he] wouldn't want it to be any different really." His wife also discussed how her appreciation for life has increased. She said, "I appreciate life more and there are times where I wake up and I think, ' A m I still trying? Do I have her?" And I do. And when I realize that, I'm just so happy." The curative nature of this mother's joy was expressed over and over again throughout the interviews. One mother was so overcome by the birth of her child that she believed that all of the trials and tribulations of her fertility struggles were worthwhile. She declared, "We enjoyed the pregnancy and now having her.. .well even the day that she was born, it was worth all the intrusive and medical interventions that we went through." Like the other participants in the study, the delight that this couple experienced becoming parents helped them put their infertility experience behind them for the time being. 85 • Another notable change for these couples was their newfound sense of belonging to the fertile world. One woman spoke of feeling more like a "normal" person and a "part of the community" now that she was a mother. She said: I feel more confident now. I had felt [like I was] kind of shying away from everybody, now I just feel more normal. So it's kind of put a bit of closure to that whole scene. Feeling like a part of the group of other mothers/women was very significant to this woman. A l l of the participant mothers commented on the fact that during their struggle with infertility they avoided situations that would bring them in contact with pregnant women or new mothers. However, this particular woman had isolated herself from family members as well, which had caused some distress for herself and her partner. Another mother commented on the fact that she and her husband had "finally arrived" and that she no longer felt left out. As she pointed out, "I don't feel left back or left out when I hear [about] people getting pregnant anymore like I did before. I mean I was out, you know, looking in ... we are now in!" This couple, in particular, seemed to have left their infertility behind them as was reflected in the following statement: But, oh yeah.. .infertility.. .there isn't.. .1 mean once you're a parent, you're a parent. I mean, and i f [you] are pregnant and are expecting then, [you] are not infertile anymore... It was very clear that this couple saw the birth of their child as the end of their infertility. Not all of the couples shared this view to the same extent, however most couples tended not to dwell on their previous fertility struggles. 86 In fact, the couples in this study by and large saw their experience of parenthood as being the same as all other parents.' One mother stated quite clearly that she doubted whether her transition to parenthood was much different from those who had conceived without difficulty. She said: But in many ways it's the same thing. I don't think our experiences are different because we had, we were going through infertility.. .When I'm talking to other friends and people, they all pretty-much, go through a lot of [similar] things... This mother recognized that becoming a parent for the first time was a transition no matter how one entered parenthood. She realized that many of the challenges and adjustments that she had experienced were not unique to her but shared by many new mothers. < Another mother expanded on her belief that parenthood after infertility was not qualitatively different than becoming a parent without having undergone fertility difficulties when she said: I mean, parenthood after infertility, other than the fact that you might appreciate certain things more and be more sensitive to other people i f they are going through [it].. .But other than that I think it's the same.. .especially with the first child.. .it's the same experience as any other parent. I don't know [if] I'd be any more happy with [the baby] as opposed to i f [the baby] was here earlier. For this woman, i f a difference in experience existed, she felt it was only in terms of her sense of appreciation and gratitude for her child and her role as a mother and not in the day-to-day functioning of being a parent. 87 On one hand the couples in this study stated that their experience of parenthood was likely very much the same as that of any other new parent but on the other hand, they also acknowledged that their experiences were somewhat unique due to their history of infertility. One difference appeared to be a heightened sense of anxiety in the early stages of pregnancy. Similar to many fertile women who feel concerned about the possibility of first trimester miscarriage, these women also expressed a fear of having to return to the stress and strain of infertility. One woman's words captured this sentiment: [I felt] maybe I don't deserve.. .didn't deserve to get pregnant for some reason, I . wasn't getting pregnant...could something take that away from me? There was a fear of losing that and being back to square one. You just don't want to go back there. This mother also stated, however, that after her 8-week ultrasound they knew everything was going fine. The pregnancy felt strong and she did not subsequently concern herself with worry. N Another couple also felt relief after the initial ultrasound. The confirmation that everything looked good helped to curb their concern that the pregnancy might not be viable. The mother commented: So when the pregnancy occurred there was just nothing but.. .joy. I mean, I think there was a little bit of a surprise, like 'Wow, like are you sure?' That's the one thing you don't want is for that to be taken away. 'So are you sure? Are you sure?' And then just wait until that 8-week ultrasound or that 7-week ultrasound that they give you and it was a surprise that we actually saw the heart beating and 88 heard it and just.. .WOW ... like.. .It was less than a pinhead (laughs) in size but it was ours and it was for real and it looked good. For this couple, as with the others in the study, there was a sense of cautious disbelief at their positive pregnancy test but it wasn't until their ultrasound at 7 or 8 weeks that they could really believe everything was going to be ok. These couples had been let down many times before so when a pregnancy did occur, they needed to safeguard themselves a little from the disappointment of something going wrong early in the pregnancy. This stress and uncertainty was particularly pronounced for one couple in the study who had a previous miscarriage. This couple waited several months before sharing the news of their pregnancy. The mother recalled: We both thought, 'let's not get our hopes up because we don't know it's going to work this time or whatever,' that I could have another miscarriage right? .. .1 remember having a lot of cramping and I really thought that I wasn't going to, wasn't going to be able to keep it and so my doctor said, 'well why don't we send you in for an ultrasound because that wil l make you feel better.' So we went in and of course they couldn't see anything, right? But they just said, you know, everything looks ok and everything's good and stuff like that so.. .and it was funny 'cause I waited a long time to tell, like I think I waited until I was almost 4 months pregnant to tell people at work and stuff because I was just so scared that it wasn't going to work, you know? So I didn't want to let people know. Due to their previous trauma of having to inform many people that they had miscarried, this couple needed to make certain that this was a viable pregnancy. Each couple in this study had had an early ultrasound, which helped to reassure them that all was well. From 89 that point on, the other three couples in the study felt that their pregnancy was strong and surrendered their fear of miscarriage. However, this couple needed to get past the first trimester before being able to do so. A second aspect of these couples' transition to parenthood experience that they felt was unique from their fertile counterparts was a lingering awareness of their infertility. Overall, the couples appeared to put their previous infertility aside once they became parents; however, this seemed to change once they began to consider a second child. As one mother commented: I kind of closed the door on infertility and I didn't think about it again. It's only now, since we're thinking of having another one that it has started cropping up i again. Once again, it appeared that a fear of returning to the emotionally taxing process of infertility caused some anxiety. This was expressed by the words of one mother: We started trying last month and the first month it didn't work. I was upset and I thought the whole thing is going to start all over. And then it's like some of the people in the [new parents] group are already pregnant so that was like.. .that was hard.. .so.. .It's a fear of being.. .1 don't want to go back down that slope again. So right now I'm 14 days late for my period but I'm scared to take a pregnancy test 'cause I don't want to have another negative. It's crazy. As with the other participants, this woman was not only fearful of being unable to conceive a second child, but was scared of returning to the up and down roller-coaster ride of her previous infertility experience.' Despite the apparent positive effects of 90 parenthood on these couples, their infertility had not been "completely healed" but had been put aside temporarily. Due to their personal reproductive histories, the women in this study were very aware of their reduced chances of conceiving again without medical assistance. One woman shared her concerns about her future reproductive capabilities: I think about, am I going to have to go through fertility treatments again. And I think about my age. I'm now getting to an age period where even i f I didn't have primary, i f we didn't experience primary infertility that we might start to experience secondary just because [my husband] is now older and I'm now older and when are we ready for another child? It might be a year or two down the road. I'm going to be more than 35 so everything.. .the age adds into, plus our past experience. This woman was very much aware of the many factors that could contribute to her difficulty in conceiving for a second time, one of which was her increasing age. The couples in this study were intimately aware that time was of the essence in terms of fighting infertility. Consequently, the couples tended to begin thinking about a second child while their first-born was still fairly young. One mother, in response to her husband's comment that he no longer thought about their previous infertility, commented on her significant dilemma over thinking about increasing their family size: I do. You know why? Because I think about siblings. And I think about our embryos. We have left over embryos that are at the clinic and they are frozen. And you know you can.. .you do your research and you see the cells, you know 91 cells on videos or whatever and you can think, 'well they're just cells,' but the thing is, one of those embryos grew into this little [child] that I love. [Pointing to her child] This is the potential of those, and so we have potential siblings up there on ice and I don't want to abandon them. I don't want to discard them, I don't want to donate them to surrogacy and i f . .when we're ready for another child.. .1 can't forget that there's those embryos at the clinic. And also I think about, well what is my body doing now? How willing would it be to conceive without any interventions? And second.. .it makes me.. .1 think about fertility issues when I think about adding another child. I mean even i f my body responded and got pregnant on its own I would still be thinking about those embryos that are in storage. The process of infertility was clearly not over for this mother. The birth of her child did not erase her previous experience nor did it signify an end to the never-ending treatment decisions she was required to make in her pursuit of parenthood. In summary, parenthood was, in many ways, reported to be a positive healing experience for the couples in this study. Their stress levels had decreased and much of the pain of infertility had been put aside. However, the process of infertility was not entirely over for these parents. They remained cognizant of their previous infertility struggles during the beginning stages of their pregnancy and when considering the possibility of pursuing pregnancy for a second time. 92 Chapter Five DISCUSSION The purpose of this study was to gain insight into the lived experiences of those making the transition to parenthood after a history of primary infertility. A n exploratory phenomenological research design was utilized with the desire of providing an "overall description of the meaning and the essence of the experience" (Creswell, 1998, p. 150) in question. Five themes emerged from an analysis of the research data, which illuminate the shared experiences of the four married couples that participated in this study. In the first section of this chapter, I compare the significant findings from this study to the relevant literature reviewed in Chapter Two. In the second section of this chapter, I address considerations for further research and discuss the implications of this study in terms of clinical practice. Comparison with the Literature A comparison between the available research and the results of this study indicates that the experience of the transition to parenthood for these previously infertile couples is in many ways similar to that of couples who become parents without fertility difficulties. The transition to parenthood literature suggests that parenthood introduces a new set of demands on, a couple that appear to require significant lifestyle reorganization I (e.g. Cowan & Cowan, 1995; Helms-Erikson, 2001). Consistent with this literature, the couples in the current study listed sleep deprivation, decreased time for themselves and each other, chronic tiredness, a curtailment of social contacts, and a decrease in marital i intimacy as some of the ways in which the arrival of their first child had brought change to their daily lives. Despite the apparent similarity in experience to their fertile 93 counterparts however, the couples in the current study appeared to adapt to these changes with greater ease and less disruption than what is described as common in the transition to parenthood literature. It has been suggested that the transition to parenthood can be a time of increased personal stress and decreased marital satisfaction for many couples (e.g. Cowan & Cowan, 1992; Knauth, 2001). This sentiment was not supported by the findings of the current study. In fact the opposite appeared to be true. The previously infertile couples in this study expressed a decrease in personal stress and a sense of renewed connection to their spouses. The stresses of new parenthood for these couples appeared to be significantly less than the stress experienced while undergoing investigations and medical interventions in their pursuit of parenthood. Cowan and Cowan (1992), in their ten-year comprehensive study, investigated marital change during the transition to parenthood. They found that during this transition gender roles became more traditional and less egalitarian with respect to the division of labour and childcare with new moms disproportionately assuming the required new tasks. This finding has been replicated in numerous studies (e.g. Helms-Erikson, 2001; Levy-Schiff, 1994) and is considered to be the greatest source of marital conflict (Cowan & Cowan, 1995) and the most problematic and important area of family reorganization for new parents (Knauth, 2001). However, this did not appear to be the case for the couples in the current study. Each couple described their transition in terms of a partnership and appeared to share tasks, with each parent being actively involved to varying degrees in the daily care of their child depending on their work circumstances. It is important to note that two of the four couples had unique job situations that allowed for a more 94 equitable division of labour. Nevertheless, a sense of resentment towards one another in terms of inequitable responsibility for childcare was not expressed by any of the couples in the study. Within the available literature, it is also recognized that new parenthood does not affect all marriages in the same way and that the transition to parenthood is not necessarily a recipe for marital distress (e.g. Levy-Schiff, 1994; Shapiro, Gottman, & Carrere, 2000). For example, couples faring well before the transition are more likely to adapt well after the baby's arrival. Despite the significant stresses of infertility, three of the four couples in the current study appeared to be united and close during their pursuit of parenthood and the one couple that expressed some marital discord sought counselling prior to conceiving their child. The fact that the couples in the study adapted to new parenthood with relative ease may, in part, be a reflection of the strength of their relationships prior to becoming parents. In a discussion paper on the determinants of marital change during the transition to parenthood, which was based on a review of the literature, Knauth (2001) also noted that "men and women who have positive attitudes toward parenting and are comfortable with the responsibilities, restraints, and commitments associated with the parenting role.. .experience less decline in marital satisfaction" (pp. 169-170). The findings from the current study appear to lend support to this claim. Due to the fact that these previously infertile couples had to question and recommit to parenthood repeatedly, they all said they felt very ready to become parents. Their expectations appeared to have been realistic, stating that nothing about the transition to parenthood had taken them by surprise. Furthermore, these couples were very positive about their parenting role, a role 95 that had been very much desired and sought after and one that had eluded them for months or years. When their child finally arrived they were very grateful for the opportunity to be parents, did not take their parenting role or their partner or their child for granted, and reported being able to take the challenges of new parenthood in stride. Overall it seems that, for the previously infertile couples in the current study, the transition to parenthood was made with greater ease than is reported in the literature for fertile couples. It may well be that having had to cope with the experience and formidable stresses of infertility and medical treatment, provided these couples with additional resources/strengths in their adaptation to parenthood, a fact that refutes much of the available literature on the transition to parenthood after infertility (e.g. Burns, 1990; Garner, 1985; Olshansky, 1990). Several articles, based solely on anecdotal and clinical evidence, suggest that previously infertile couples may experience unique challenges adjusting to parenthood as compared to couples without a history of fertility impairment (Bernstein, 1990; Garner, 1985; Olshansky, 1990). Garner, in her landmark study looking at pregnancy after infertility stated that the achievement of pregnancy, for many, does not eliminate the emotional aspects of infertility. Specifically, she claimed that the past experiences and feelings associated with infertility might actually increase the normal stresses of pregnancy, which could ultimately affect couple's parental role development. However, the findings from the current study fail to substantiate Garner's claims. The couples in this study described parenthood as being a positive, healing experience that allowed them to put aside their infertility and enjoy the experience of being parents; at least until the issue of having a second child became salient. 96 1 Consistent with some of the literature however, these couples did express having experienced a heightened sense of anxiety at the very early stages of their pregnancy. During their infertility their bodies had repeatedly failed them and they were fearful of being thrust back into the maelstrom of infertility i f they miscarried. However, fear of miscarriage was eliminated for three of the four couples by their 7-week ultrasound and after the end of the first trimester for the remaining couple. Fortunately, all four couples had relatively normal pregnancies and all delivered healthy babies. Olshansky (1990) and Bernstein (1990) also listed numerous potential after effects of infertility on the postpartum experience and the transition to parenthood. Olshansky suggested that a couple's prior struggle with infertility, which often leaves a couple with diminished resources, may exacerbate the feelings of fatigue experienced by most new parents and make it more difficult to come to terms with the profound changes a baby has on parents' lives. The couples in the current study, however, appeared to adapt with relative ease to parenthood, a finding that refutes much of what is found in the transition to parenthood literature. Both Olshansky and Bernstein caution that previously infertile couples may have difficulties reconciling their idealized vision of their parenthood experienced during their time of infertility with the reality of their parenting experience. However, the couples in the current study stated that their expectations of parenthood had been realistic. The only unexpected outcome of parenthood noted by these couples was the level of joy and love that they experienced which was greater and deeper than they had ever anticipated. Bernstein (1990) also listed several residual outcomes of infertility that could potentially affect successful parenting. These included decreased self-esteem, an altered 97 body image, impaired marital communication, decreased sexual intimacy, and isolation from family and friends. The findings from the current study markedly refute these claims primarily due to the fact that, for these couples, parenthood was a healing experience. The couples in the study expressed an increase in self-esteem after conceiving and becoming parents. They stated that they felt 'normal' again. No longer were they 'outsiders' looking in on a world that they wanted to be a part of. The ability to conceive and carry a child to term also helped the women in the study to experience a renewed appreciation for their bodies. As one woman stated, "I hated my body before, 'cause it was not doing what it had to do." What was once broken now worked. The couples in this study also expressed a sense of new connection to their partners that appeared to strengthen their marital bond and increase their feelings of closeness and intimacy based on an appreciation for their partners as parents. Finally, the arrival of their children appeared to help reopen contact with family and friends. The women in this study stated that during their time of infertility they avoided situations that would remind them of their childlessness, such as baby showers and family gatherings. Once they became parents, they began to feel like part of the group and no longer felt the need to isolate themselves from family and friends. The works of Garner (1985), Olshansky (1990), and Bernstein (1990) caution health practitioners that individuals and couples with a prior history of infertility may have unique difficulties and special needs as they make the transition to parenthood. While the findings of the current study appear far more optimistic than what has been outlined in these articles, the transition to parenthood was not without its issues and challenges for these couples. 98 i Olshansky (1990) states that previously infertile couples may have difficulty above and beyond those of other pregnant couples because of the "identity shift" they're required to make from "self as infertile" to "self as fertile." She suggests that i f this issue is left unresolved, associated difficulties may continue throughout the transition to parenthood. The findings of the current study appear to lend some support to this idea. While the women in the study reflected on how they were able to put their infertility aside during their pregnancies, this appeared to be only temporary. The couples were aware that while they had now "joined the parenthood club," they were still different. They were still infertile couples and when they began to think about having a second child, their previous fears and concerns about their ability to reproduce returned. However, it is important to note that while each couple expressed a fear of returning to the stresses and disappointments of infertility treatments, the degree of fear differed between couples. One woman stated that she didn't feel as desperate pursuing the second pregnancy as she did the first. But another participant who was hoping to have a second child acknowledged that despite being 14 days late for her period she was avoiding taking a pregnancy test because she was so fearful of receiving a negative result. Bernstein (1990) also noted that some previously infertile couples might have ethical and emotional issues to work through related to assisted reproduction, adoption, or third party donation. The current study did not include couples that became parents through adoption or donor insemination. However, two of the four couples pursued parenthood through assisted reproduction. Both of these couples reflected on the difficulty they experienced making treatment decisions and one couple spoke at some length and with great emotion over the ethical dilemma that remained about what to do 99 with the remaining embryos cryopreserved in storage. For this couple in particular, their experience of infertility remains ever present until a final decision is reached and acted upon in terms of the disposition of these embryos. Empirical studies on the transition to parenthood after infertility have had inconsistent results. Some appear to substantiate the anecdotal and clinical evidence that suggest that the negative effects of infertility may persist throughout pregnancy and postpartum, and ultimately impact the family's future functioning (Burns, 1990; Dunnington & Glazer, 1991). As already stated, the findings from the current study do not appear to substantiate these claims. Other studies have refuted the notion of a negative impact of infertility on future parenting (Abbey, Andrews & Halman, 1994; Allen, Maguire, Williams & Sanger, 1996; Hahn, 2001; Holditch-Davis, Sandelowski & Glenn Harris, 1998). One major finding of the current study is that for these previously infertile couples, parenthood has been experienced as a positive, healing experience. This appears to lend support to Abbey et al.'s (1994) contention that becoming a parent after infertility might actually increase a person's overall well-being, at least for previously infertile women. The purpose of their study was to "examine the impact of becoming a parent on members of infertile couples (p. 398)." Like the present study, the researchers interviewed both members of the couple but they also included a comparison group of supposedly fertile couples. They found that becoming a parent produced an increase in global life quality for previously infertile women and that these women experienced additional positive effects to their psychological well-being during the transition to parenthood as compared to their husbands and their fertile counterparts. The previously 100 infertile men appeared to experience greater home life stress than did their wives and the nonparents. Abbey et al. suggested, "after years of trying to have a child, previously infertile men may be particularly sensitive to their changed household responsibilities and their wives' expectations for their performance (p.402)." Interestingly, similar to their wives and contrary to Abbey et al.'s findings, the previously infertile men in the current study also expressed an increased sense of well-being, a fact that appears to extend what we know from the work of Abbey et al. This may reflect the fact that the participants in this study appeared to have had fairly equal partnerships both prior to and after becoming parents. Due to the qualitative nature of the current study, reported increases in well-being on the part of the four couples in this study cannot not be measured or compared. It is not known whether the women's overall well-being increased more significantly than that of their husbands. However, the women in the present study did seem to express experiencing more difficulties and distress than their partners during the infertility process. They suggested that this was due in part to the painful and invasive procedures that they were required to undergo in the pursuit of parenthood but also to the emotional monthly reminder of their body's inability to conceive. Therefore, despite the fact that both the men and women in this study reported experiencing a decrease in stress and a sense of healing and increased well-being after becoming parents, it is possible this may have represented an even greater change for the women from their pre-pregnant, infertile state. Abbey et al. (1994) also concluded that parenthood might actually mitigate the negative effects of infertility for some women, a finding that was substantiated by the 101 current study. However, these researchers also found that the effect of parenthood on previously infertile men was not as encouraging in terms of reporting greater home life stress than any other group in the study. This finding was not replicated in the present study. The amount of home life stress appeared to decrease for both members of these couples. The difference in findings might be explained by the fact that Abbey et al. (1994) included previously infertile couples that had become parents through adoption and those who had multiple births, as well as couples who had already become parents for a second time and were therefore not in the midst of making the transition to first-time parenthood. Research has demonstrated that the experience of new parenthood for couples with multiples is different from that of singletons (e.g. Weigel, Auxier, & Frye, 2000) and that the processes underlying the transition to parenthood in adoptive and biological families differ from one another (e.g. Levy-Schiff, Goldschmidt, & Har-Even, 1991). The addition of a second child may also amplify family stress due to an increase in the challenges and demands of parenting. The notion that a history of infertility puts parents at increased risk for parenting difficulties was also not supported by the findings of Allen et al. (1996). In their quantitative study on the effects of infertility on parent-child relationships and adjustment, these researchers compared previously infertile women to a control group of women who had voluntarily delayed pregnancy before becoming parents on a variety of measures. Their results suggested that the transition to parenthood for those who involuntarily delayed pregnancy was no more challenging than for those who voluntarily delayed pregnancy. In fact, the control group who had voluntarily delayed parenthood actually reported higher scores on several aspects of the Parenting Stress Index than did 102 \ the infertile group. The findings from the current study appear consistent with those reported by Allen et al. and extend their results by including fathers as well as mothers. After becoming parents, the previously infertile couples in the present study reported few complaints about the demands of parenthood, a better relationship with their spouse, and a decrease in stress from their previous infertile state. Furthermore, these couples also stated that their immense appreciation for their child has positively affected the quality of their relationship with their child. The findings from the current study also appear to corroborate Hahn's (2001) critical review of the empirical literature on the psychosocial well-being of parents and children born after assisted reproduction. She found that "the psychosocial functioning of parents and their children born after assisted reproduction is more similar than dissimilar (p.530)" to that of fertile control families and that previously infertile parents with children born using in-vitro fertilization tended to report less parenting stress and more positive parent-child relationships than parents without fertility difficulties. The findings from the present study also suggest low reported levels of parenting stress and positive parent-child relationships among the participants, lending support to Hahn's conclusions. For example, one couple remarked that they believed that their overflowing happiness at having become parents has had a reciprocal effect on their child. Hahn did caution, however, that her findings might reflect a more positive conclusion than what is true in reality because the parents might feel they should not display anything other than gratefulness. Nevertheless, based on the findings of the current study, there was no need for this caveat. The couples showed no sign of withholding complaints because of a need 103 to appear grateful. They simply stated that they were grateful and that they took neither their role as parents nor their child for granted. Finally, Sandelowski (1995) proposed a theoretical synthesis of the transition to parenthood of infertile couples that outlined reconstructive and repair work exclusive to infertile expectant parents and previously infertile new parents. She described processes that all couples, regardless of their fertility status make during the transition to parenthood, as well as some additional physical, emotional, and interpretive work of recovery, repair, and reconstruction required by previously infertile couples. The additional work includes four different tasks: facing infertility, mazing, relinquishing infertility, and reconstructing infertility. Specifically, the process is one in which couples acknowledge their infertility, pursue parenthood through a recursive and often capital-intensive process, divest themselves of their infertile identity, and then seek to understand and gain interpretive control of their infertility experience. Sandelowski's theory included parenting children conceived after both primary and secondary infertility, as well as through assisted reproduction, donor insemination and adoption, encompassing a far broader range than what was under investigation in the current study. Nevertheless, the findings of the present study revealed that while the four couples were able to put aside their issues of infertility during pregnancy, they reappeared once the couples began to consider increasing their family size. As long as these couples had the desire to reproduce, they appeared unable to completely rid themselves of their infertile identity, thoughts, feelings, and behavior patterns. This lends some support to Sandelowski's claim that there may be recovery and repair work required for some previously infertile couples making the transition to parenthood. 104 Implications for Future Research In this section I will attempt to delineate suggestions for future research based on the limitations of the current study and the differences between the findings of this study and the available research. The demographic characteristics of the four volunteer couples were typical of those found in the infertility literature (e.g. Daniluk, 2001). The participants were primarily: white, well-educated, middle-to upper class North Americans of European descent. While this is the population that tends to seek infertility treatment, it might be interesting to investigate the lived experiences of previously infertile couples that did not have the financial resources to pursue medical treatment or those who went into debt to pursue treatment and now have that additional stress to contend with. The one couple in this study with the lowest household income did not pursue traditional infertility treatment and therefore was not as financially burdened as they might otherwise have been. It would be interesting to know whether or not the transition to parenthood for couples economically stressed after fertility treatment is the same as for those less financially burdened. Further research might also help to uncover whether parenting after infertility is notably different for those from another cultural background. For instance, it would be interesting to know whether members of various cultures experience more or less social and familial pressure to reproduce and the extent to which different parenting role options are considered acceptable. In addition, specific personal and relationship factors such as the length of the relationship, duration of infertility prior to successful conception, marital health prior to making the transition, and the level of desire for parenthood on the part of 105 both members of the couple might also play a role in the experience of parenting after infertility. As stated in Chapter Three, the results from this study are not generalizable to all r couples that make the transition to parenthood after primary infertility. Numerous infertile couples become first-time parents of twins or triplets. Other couples become parents through adoption or third-party donation. Further research might reveal whether or not the experiences of these parents are similar to those of the couples in this study. The present findings are also limited to the experiences of infertile heterosexual couples. It would be interesting to see i f the findings would be different based on sexual orientation by replicating this study with infertile lesbian couples. Finally, a significant limitation of the current study pertains to the relatively small sample size. Only four previously infertile couples who fit the research criteria were ultimately interviewed. Repeating this research with a larger sample of couples might help to determine whether or not the themes could be replicated or further refined. It might also help to uncover themes left unnoticed in the present study. Furthermore, replicating this study might also determine whether the largely positive findings of the present study are an accurate reflection of the experience of couples parenting after infertility or a reflection of the unique characteristics of the self-selected participants. Struggling parents may not have elected to^participate. 106 Implications for Clinical Practice In this section, the implications for clinical work with infertile couples making the transition to parenthood will be examined based on the findings of this study. The current study represents good news for couples making the transition to parenthood after primary infertility. Contrary to the previous anecdotal and clinical accounts of the potential negative impact of infertility on pregnancy and parenthood, this study suggests that previously infertile couples may in fact make the transition to parenthood with greater ease than their fertile counterparts. The findings suggest that, having coped with the stresses of infertility these couples may have considerable personal and relationship resources to assist them in negotiating their transition to parenthood. These include a certain readiness for the tasks of parenthood, a decrease in personal stress in not having to cope with the stresses of infertility unless and until they elect to increase their family size, strengthened self-esteem, a feeling of renewed connection and closeness to their spouse, and sincere gratitude and appreciation for their child and for the chance to be a parent. Therefore, it may be important for counsellors working with couples from this population to check their own assumptions about the potential negative effects of infertility on the transition to parenthood when working with these clients. False assumptions may get in the way of a counsellor's ability to accurately "hear" their clients' story. Looking for problems instead of focusing on strengths could interfere with their ability to work effectively with their clients and could potentially cause harm. Consistent with claims made in some of the research related to the transition to parenthood after infertility, the couples in this study expressed a sense of heightened anxiety at the beginning stages of their pregnancies (e.g. Bernstein, 1990; Garner, 1985). 107 This is not surprising since they were well aware of and accustomed to a cycle of rising hope that was far too often followed by disappointment and grief. If couples seek counselling during this time, it might be useful for counsellors to explore their clients' fears and to help normalize them (Olshansky, 1990). It may also be important for counsellors to prepare their clients for the possibility of a negative ultrasound since 20% of all pregnancies end in miscarriage (Corson, 1999). Knowing the percentage for miscarriage may help decrease their sense of accountability and responsibility for a failed pregnancy. Couples may experience some anxiety until they receive tangible evidence that all is well with their pregnancy and those who receive negative news no doubt will need even more support and assistance with their grief and with their subsequent treatment decisions. For the couples in this study, fear and disbelief appeared to dissipate after having an ultrasound and being able to see their child's heart beating. Two of the four couples in this study became parents through in-vitro fertilization. One of these couples acknowledged experiencing recurring significant emotional and ethical distress over their dilemma of what to do with the embryos remaining from their treatment cycle. While all couples may not share this concern, it has been documented in the infertility literature that the method by which a child is conceived or enters the family can create a unique set of challenges for the individual or couple (Glazer, 1998); therefore, counsellors may wish to explore whether or not this is an issue for their clients. If so, counsellors may assist their clients by having them examine their options and their feelings surrounding those options in order for them to make an informed choice about what to do with any remaining embryos. The meaning of the embryos for each individual is central to this decision, as are religious beliefs about the sanctity of life and when life 108 begins, and may need to be explored. Counsellors can provide further support through future treatment cycles or through the grieving process i f clients decide to donate or -destroy their embryos (Daniluk, 1997). Despite the fact that for the couples in this study parenthood was a positive, healing experience, all remained cognizant of their infertility status. Some participants expressed feeling like they had one foot in and one foot out of the "fertile world of parenthood." When associating with other new parents, these couples at times felt like they were not a part of the group due to having a "different parenthood story." The dissonance between feeling both inside and outside of the fertile world may be another potential counselling issue. Counsellors may be able to support these clients by helping them explore aspects of new parenthood that are a shared experience regardless of previous fertility issues. Another focus for counselling may be helping clients reconnect with significant others i f some of these relationships have been significantly disrupted during infertility. Finally, the couples in this study were able to put aside their infertility only until they began to think about having another child. The feelings and anxieties associated with their previous infertility experience came flooding back once they began to consider pursuing parenthood for a second time. Consistent with the literature this suggests that for these couples the process of infertility was not over when they became parents (e.g. Garner, 1985; Sandelowski, 1995). Not only did they express a fear of not being able to conceive another child, they expressed a very real fear of returning to the dark and negative place of their previous infertility experience. Counsellors who are working with men and women who parent after infertility may benefit from understanding that the 109 process of infertility may not be over for these clients despite having successfully conceived and carried a child to term (Glazer, 1990). They are still infertile couples who aren't likely to be able to increase their family size without medical assistance and intervention. Counsellors can help these couples by providing support during their renewed pursuit of parenthood, as well as assisting them with identity issues surrounding their infertility (Gerrity, 2001). Counsellors can assist during treatment cycles by teaching relaxation and stress-reducing techniques (Daniluk, 1991). It may also be beneficial for counsellors to acknowledge their clients' feelings of loss and grief after any subsequent failed attempts to conceive (Eunpu, 1995). This could be particularly salient for this population as having finally been successful in conceiving, they may go into subsequent treatments with greater expectations of success a second time. However, the good news is, that in already being parents, the stakes are not as high the second time for most couples. 110 References Abbey, A. , Andrews F .M. , Halman, L.J. (1991). 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Covington (Eds.), Infertility Counseling: A Comprehensive Handbook for Clinicians (pp.449-472). New York, N Y : Parthenon Publishing Group. Colaizzi, P. (1978). Psychological research as the phenomenologist views it. In R.S. Valle & M . King (eds.), Existential-phenomenological alternatives for psychology (pp. 48-71). N Y : Oxford University Press. Corson, S.L. (1999). Conquering infertility: A guide for couples (4 t h ed.). Vancouver, British Columbia: EMIS. Cowan, C P . , Cowan, P.A., Heming, G., Garrett, E., Coysh, W.S., Curtis-Boles, H. , Boles, A.J . (1985). Transitions to parenthood: His, hers, and theirs. Journal of Family Issues, 6, 451-481. Cowan, C P . & Cowan, P. A. (1992). When partners become parents: The big life change for couples. New York: BasicBooks. Cowan, C P . & Cowan, P.A. (1995). Interventions to ease the transition to parenthood: Why they are needed and what they can do. Family Relations, 44, 412-423. Creswell, J.W. (1998). 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JOGNN: Journal of Obstetric, Gynecologic and Neonatal Nursing, 20, 309-318. Eunpu, D.L. (1995). The impact of infertility and treatment guidelines for couples therapy. The American Journal of Family Therapy, 23, 115-128. Garner, C.H. (1985). Pregnancy after infertility. Journal of Obstetric and Gynecologic Neonatal Nursing, 14, 58s-62s. Gerrity, D.A. (2001). Five medical treatment stages of infertility: Implications for counselors. The Family Journal: Counseling and Therapy for Couples and Families, 9, 140-150. Gibson, D . M . & Myers, J.E. (2000). Gender and infertility: A relational approach to counseling women. Journal of Counseling & Development, 78, 400-410. Glazer, E.S. (1990). The long-awaited stork: A guide to parenting after infertility. Lexington, M A : D.C. Heath and Company. Glazer, E.S. (1998). Experiencing infertility (Rev, ed.). San Francisco: Jossey-Bass. Golombok, S., MacCallum, F., & Goodman, E. (2001). The "test-tube" generation: Parent-child relationships and the psychological well-being of in vitro fertilization children at adolescence. Child Development, 72, 599-608. Greenfeld, D. & Klock, S.C. (2001). Transition to parenthood among in vitro fertilization patients at 2 and 9 months postpartum. Fertility and Sterility, 76, 626-627. 112 Hahn, C.S. (2001). Review: Psychosocial well-being of parents and their children born after assisted reproduction. Journal of Pediatric Psychology, 26, 525-538. Helms-Erikson, H . (2001). Marital quality ten years after the transition to parenthood: Implications of the timing of parenthood and the division of housework. Journal of Marriage and Family, 63, 1099-1110. Hobbs, D.F. (1965). Parenthood as crisis: A third study. Journal of Marriage and the Family. 27. 367-372. Holditch-Davis, D., Sandelowski, M . , & Harris, B .G. (1998). Infertility and early parent-infant interactions. Journal of Advanced Nursing, 27, 992-1001. Holditch-Davis, D., Roberts, D., Sandelowski, M . (1999). Early parental interactions with and perceptions of multiple birth infants. Journal of Advanced Nursing, 30, 200-210. Hollingshead, A . B . (1975). Four factor index of social status. New Haven, CT: Yale University. Knauth, D.G. (2001). Marital change during the transition to parenthood. Pediatric Nursing, 27, 169-172. Kvale, S. (1983). The qualitative research interview. Journal of Phenomenological Research, 14, 171-196. LaRossa, R. (1983). Timing of the first birth. Journal of Marriage and the Family, 45, 553-567. Lee, S. (1996). Counselling in male infertility. Cornwall, U K : Blackwell Science. Leiblum, S.R. (1997). Love, sex, and infertility: The impact of infertility on couples. In S.R. Leiblum (Ed.), Infertility: Psychological issues and counseling strategies, (pp. 149-166). New York: John Wiley. Leiblum, S.R. & Greenfeld, D.A. (1997). The course of infertility: Immediate and long-term reactions. In S.R. Leiblum (Ed.), Infertility: Psychological issues and counseling strategies, (pp. 83-102). New York: John Wiley. LeMasters, E.E. (1957). Parenthood as crisis. Marriage and Family Living, 19, 352-355. Levy-Shiff, R., Goldshmidt, I., & Har-Even, D. (1991). Transition to parenthood in adoptive families. Developmental Psychology, 27, 131-140. 113 Levy-Shiff, R. (1994). Individual and contextual correlates of marital change across the transition to parenthood. Developmental Psychology, 30, 591-601. MacDermid, S.M., Huston, T.L., & McHale, S.M. (1990). Changes in marriage associated with the transition to parenthood: Individual differences as a function of sex-role attitudes and changes in the division of household labor. Journal of Marriage and the Family, 52, 475-486. McMahon, C.A., Ungerer, J.A., Tennant, C , & Saunders, D. (1997). Psychosocial adjustment and the quality of the mother-child relationship at four months postpartum after conception by in vitro fertilization. Fertility and Sterility, 68, 492-500. McShane, P .M. (1997). Infertility diagnosis and assisted Reproductive Options: A primer. In S.R. Leiblum (Ed.), Infertility: Psychological issues and counseling . strategies, (pp. 20-40). New York: John Wiley. Menning, B.E. (1982). The psychosocial impact of infertility. Nursing Clinics of North America. 17. 155-163. Miller, B.C., & Sollie, D.L. (1980). Normal stresses during the transition to parenthood. Family Relations, 29, 459-466. Olshansky, E.F. (1990). Psychosocial implications of pregnancy after infertility. N A A C O G S Clinical Issues in Perinatal Women's Health, 1, 342-347. Osborne, J. (1990). Some basic existential-phenomenological research methodology for counsellors. Canadian Journal of Counselling, 24, 79-91. Osborne, J. (1994). Some similarities and differences among phenomenological and other methods of psychological qualitative research. Canadian Psychology, 35, 167-189. Rew, L., Bechtel, D., & Sapp, A. (1993). Self-as-instrument in qualitative research. Nursing Research, 42, 300-301. Sandelowski, M . (1995). A theory of the transition to parenthood of infertile couples. Research in Nursing & Health, 18, 123-132. Sandelowski, M . , Holditch-Davis, D., & Harris, B.G. (1992). Using qualitative and quantitative methods: The transition to parenthood of infertile couples. In J.F. Gilgun, K . Daly, & G. Handel (Eds.), Qualitative methods in family research (pp.301-322). Newbury Park, C A : Sage. 114 Shapiro, A.F. , Gottman, J.M., & Carrere, S. (2000). The baby and the marriage: Identifying factors that buffer against decline in marital satisfaction after the first baby arrives. Journal of Family Psychology, 14, 59-70. Shapiro, C.H. (1982). The impact of infertility on the marital relationship. Social Casework: The Journal of Contemporary Social Work, 63, 387-393. Van Balen, F. (1996). Child-rearing following in vitro fertilization. Journal of Child Psychology and Psychiatry, 37, 687-693. Van Balen, F. (1998). Development of IVF children. Developmental Review, 18, 30-46. Watkins, C.E. & Schneider, L.J. (1991). Research in Counseling. Hillsdale, New Jersey: Laurence Erlbaum. Weigel, D.J., Auxier, C.R., & Frye, T . M . (2000). Multiple-birthing trends: Impact on couples and families. The Family Journal: Counseling and Therapy for Couples and Families, 8, 380-386. ) 116 Appendix B 2 Study Participant Consent Form Dialogues about Making the Transition to Parenthood after Infertility This research is being conducted by Debbie Plomp as one of the requirements for "earning a masters degree in Counselling Psychology. The purpose of this study is to understand how couples experience making the transition to parenthood after primary infertility. Participation in this study is completely voluntary and you may refuse to participate or may withdraw from the study at any time. You have agreed to participate in two interviews. The first interview will be audio taped and take approximately 1 to 2 hours. The second interview wil l take approximately 1 hour with the total time commitment being 2 to 3 hours. The purpose of the first interview is to hear about your and your spouse's experience of making the transition to parenthood after infertility. The purpose of the second interview is to provide you with an opportunity to review and confirm whether my results adequately capture the essence of your experience of parenting after infertility. Your identity will remain confidential. To ensure your anonymity, please choose and indicate a pseudonym below. Any identifying features of your accounts of making the transition to parenthood after infertility will be changed to protect your privacy. During the second interview you will be informed of and asked to approve any such ( changes. Each audio tape will be transcribed verbatim by the researcher. A l l data will be kept in a locked cabinet or under a password on a computer hard drive. Only the senior research supervisor and the researcher will have access to the audiotapes. The tapes will be erased upon completion of the study. The transcripts will be kept in a locked cabinet 2 Reference #200302 Version 01/2003-01-06 118 Appendix C 3 Orienting Statement Couple Interview The purpose of this research is to better understand how couples experience parenting their first child after having experienced infertility. Over the years, the transition to parenthood and its impact on the individual and the marriage has been studied extensively. However, relatively little is known about what it is like to finally become a parent after experiencing infertility. Please speak as freely as you wish about your experience of infertility and of becoming a parent. In order to assist me in understanding your experiences, I may ask you to elaborate on issues or clarify points as we proceed through the interview. You are under no obligation to discuss anything that makes you feel uncomfortable. You are also encouraged to ask questions or relay any concerns to me at any point throughout the interview. The principal question to which I would like you to respond is: What is your experience of making the transition to parenthood after having experienced infertility? Perhaps you can begin by telling me about your experience like a story, with the beginning being when you started trying to have children and the end being where you are now having been parents for months/years. 3 Reference #200303 Version 01/2003-01-06 119 Appendix D 4 Sample Interview Questions Principal Research Question What is the experience for couples making the transition to parenthood after a history of primary infertility? Principal Interview Question What is your experience of becoming a parent after having experienced infertility? Additional Interview Questions 1. Can you tell me a bit about what it was like for you: i) when you decided to try to have children and realized that there was a problem? ii) as you were pursuing parenthood through medical investigations and treatment? iii) when you realized that you were pregnant? iv) during your pregnancy? v) after your child was first born (e.g. during the first few months)? 2. How do you think your experience of infertility has impacted on your transition to parenthood? 3. Describe the kind of personal changes, i f any, that you have experienced since becoming a parent. 4. Describe the kind of marital changes, i f any, that you have experienced since becoming a parent. 5. What have been the greatest challenges for you individually and as a couple, since becoming parents? 4 Reference #200304 Version 01/2003-01-06 120 6. What have been the greatest gains for you individually and as a couple, since becoming parents? 7. If you were talking to another couple who was about to make the transition to parenthood after infertility, what advice would you give them? 8. What were your expectations of parenthood before becoming parents? i) Since becoming parents? 9. If you could choose a metaphor to describe your experience of making the transition to parenthood after infertility, what would it be? 

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