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Infertility and introduction of in-vitro fertilization in Nepal

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Infertility and introduction of in-vitro fertilization in Nepal a case study
Creator:
Koirala, Supriya
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English
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viii, 65 leaves : ; 28 cm

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Subjects / Keywords:
Infertility -- Nepal ( lcsh )
Fertilization in vitro -- Nepal ( lcsh )
Fertilization in vitro ( fast )
Infertility ( fast )
Nepal ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Bibliography:
Includes bibliographical references (leaves 61-65).
General Note:
Department of Sociology
Statement of Responsibility:
by Supriya Koirala.

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|University of Colorado Denver
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|Auraria Library
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All applicable rights reserved by the source institution and holding location.
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166344998 ( OCLC )
ocn166344998
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LD1193.L66 2007m K64 ( lcc )

Full Text
r
INFERTILITY AND INTRODUCTION OF IN-VITRO FERTILIZATION IN NEPAL:
A CASE STUDY
by
Supriya Koirala
B.A., University of Colorado at Denver/Health Science Center, 2004
A thesis submitted to the
University of Colorado at Denver/Health Sciences Center
in partial fulfillment
of the requirements for the degree of
Master of Arts
Sociology
2007


2007 by Supriya Koirala
All rights reserved.


This thesis for the Master of Arts
degree by
Supriya Koirala
has been approved
by
Candan Duran-Aydintidg
3/2. yJ.aj.
Date


Koirala, Supriya (M.A., Liberal Arts and Science, Sociology, University of Colorado at
Denver/Health Science Center)
Infertility and Introduction of In-Vitro Fertilization in Nepal: A Case Study
Thesis directed by Professor Candan Duran-Aydintug
ABSTRACT
The introduction of a new technology in a society always brings about social changes in the
people. The beginning of the use of IVF technology in traditional Nepal has brought about
significant changes in the lives of many infertile couples. Drawing from fieldwork and
personal interviews of 22 respondents which included doctors, nurses, doctors assistants,
and patients (husbands and wives), this study explored how the dynamics of having IVF
technology played out in the setting in which it has been recently introduced. The findings
paralleled social construction theory in that people involved in the IVF procedure socially
construct and accept their reality based on their daily social interactions. Research indicated
that each individuals perception of IVF and infertility is defined by the existing societal norms
and the society itself. As a result of existing traditional system of beliefs and values in Nepal,
there is still some stigma attached to the notion of infertility and IVF.
This abstract accurately represents the content of the candidates thesis. I recommend its
publication.
Signed


DEDICATION PAGE
I dedicate this thesis to my mother who has been my lifelong inspiration. You have been
there every step of the way, without which I would never have been able to come this far. I
also dedicate this to my father for his love and support through all these years. I love you
both dearly.


ACKNOWLEDGMENT
My heart-felt thanks to my advisor and mentor, Candan Duran-Aydintug, for all her support
and encouragement. You were always there when I needed you. I also wish to thank
Andrea Haar and Erin Amundson for their help and contribution to my thesis. I additionally
would also like to thank Sanu Shrestha for her valuable participation and involvement to my
research. Finally I want to acknowledge all the participants in this research without whom,
this thesis would have been impossible.


TABLE OF CONTENTS
CHAPTER
1. INTRODUCTION.........................................................1
2. REVIEW OF LITERATURE.................................................4
Use of IVF in the United States..................................5
Social Construction Perspective..................................6
Social and Psychological Consequences............................8
Cultural Pressures..............................................11
Ethical Issues..................................................12
External Support-Role of Doctors and Medical
Professionals.................,.................................14
3. METHODS.............................................................17
Procedure and Sample............................................17
4. FINDINGS............................................................21
Social and Cultural Pressures...................................21
Family, Cultural, and Societal Pressures...................21
Remarriage.................................................22
The Burden of Infertility..................................23
Faith or Science?...............................................25
Superstitious/Religious Practices..........................27
Husbands Support...............................................30
vii


Difficulties in IVF.....................................32
IVF as a Form of Stigma.............................33
Egg-sharing.........................................34
Financial Burden....................................36
Alternatives to IVF: Adoption...........................37
Outcome of IVF at OM Hospital...........................39
5. CONCLUSIONS.................................................42
APPENDIX
A. CHARACTERISTICS OF DOCTORS..................................46
B. CHARACTERISTICS OF PATIENTS.................................48
C. NUMBER OF BATCHES AND OUTCOME OF IVF.......................50
D. CONSENT FORM ..............................................51
E. QUESTIONNAIRE-PATIENTS.....................................53
F. QUESTIONNAIRE-MEDICAL PROFESSIONALS........................56
G. INTERVIEW GUIDELINE .......................................58
REFERENCES.........................................................61


CHAPTER 1
INTRODUCTION
The introduction of In-Vitro Fertilization or IVF at the end of the 20th century has
changed the way many families are formed. From the birth of Louise Brown, the first test-
tube baby in 1978 has ...led to the creation of family types that would not otherwise have
existed (Golombok, MacCallum, and Goodman, 2001, p.599). IVF is a procedure that
involves fertilization of an egg with sperm in the laboratory, followed by the transfer of the
resulting embryo to the mothers uterus. This technique has helped many parents who have
infertility problems to have children of their own.
The advancement in IVF technology also brings forth social issues and concerns.
Now that the knowledge and use of IVF has become fairly well known, its influences in many
realms of life are also being seen. Therefore it seems, IVF embodies social continuity while
also encapsulating a potential for radical social transformation (Birenbaum-Carmeli 2003,
p.591). As pointed out by Dr. Birenbaum-Cameli in his article, Contextualizing a Medical
Breakthrough, certain technologies like the IVF stands out as being more revolutionary than
others. Due to the measuring advancement and knowledge of this technology, it has spread
rapidly in many other countries. IVF technology has been around for over 25 years in the
United States and in many developed countries like United Kingdom and Australia. A recent
introduction of this procedure has been in Kathmandu, Nepal in 2004.
Lying in the lap of the Himalayas, landlocked between the two economic giants,
China and India, Nepal is still a developing country and is one of the poorest countries in the
world. About 38 percent of the people live on less than one U.S. dollar a day. The Gross
1


National Income of Nepal stands at U.S. $250 and 79 percent of the total population is
dependent on agriculture for their livelihood. With poor economic growth comes low literacy
rate which stand at about 50.7 percent. In addition, Nepal also has the highest number of
infant mortality in South Asia which is 98 per thousand child births. Lacking education and
proper health care, people are still very traditional in their way of life. Nepalese are still
bound to tradition and customs. The society is marked by social stratification of different
ethnic groups, religions, and caste; each having their own unique cultural mores and norms.
Social exclusion among male and female population as well as among individual caste
groups still exist to a degree. Leading a conventional way of life helps the people form their
own status and understand their place in the society. One important issue that strongly
affects Nepalese is fertility since children act as additional labor to the household, take care
of the parents during old age, and carry on the family name. In view of the fact that most
families are joint or extended families; having children also acts as a form of economic
security where the transfer of inheritance is from a father to his son. Having a biological child
is thus imperative in having a stable and happy marriage. As s result, fertility issues strongly
influence people and, therefore, have made possible the introduction and advancement of
IVF technology in this part of the world.
Since the introduction of IVF in the capital city of Kathmandu in 2004, the outcome of
this procedure has been very successful with the success rate of about 38 percent in
comparison to the pregnancy rate for IVF in the United States which approximately fluctuates
from 30 to 5 percent depending upon the age of women (Center for Disease Control and
Prevention, 2004). The introduction of this procedure definitely has an impact on family
2


relationships, peoples psychological well being, and also on the social setting of the hospital
and the society in general.
In this study, I looked at IVF in a rather traditional setting in Kathmandu, Nepal, in
order to explore how the introduction of such a technology impacted a society. The study
also concentrated on how social factors condition peoples experiences of IVF. Although
there are innumerable studies done on infertility and use of IVF, no study has looked at this
issue holistically. This study concentrated on exploring what infertility meant to individuals,
how the introduction of IVF has impacted them in terms of building hopes and facing
disappointments, how it has changed their family dynamics, and what people, in general,
think about the use of such a procedure. The purpose of this study was to explore how the
social and cultural consequences define peoples experience of IVF.
3


CHAPTER 2
REVIEW OF LITERATURE
The introduction of IVF in the United States has been extremely successful in terms
of its development, use, and acceptance in the society. A societys acceptance to adopt a
new technology is shaped by the current social conditions. This made exploring IVF issue
pertinent to its development in a society. Research done in the initial phases of IVF
introduction showed that this technology played a symbol of medical prestige (Birenbaum-
Carmeli (2002, p.593) that had significant economic value. Birenbaum-Carmeli (2003)
emphasized that the introduction of a technology is dependent on how accepting the society
is, and who in the society is in the position to make that change. To put it briefly, such
decisions seem solely based on the eagerness of women to seek treatment. Therefore, it
was seen that women played a crucial role in the advancement of IVF. In relation to IVF and
cultural factors, a study done by Birenbaum-Carmeli, Carmeli, and Cohen (2000) compared
the use of IVF in Israel and Canada based on cultural, political, and social context. In
analyzing the press coverage of IVF in these two countries, it was seen that IVF was glorified
and romanticized in Israel, whereas in Canada it was criticized. The reason for such
differences were noted to be as a result of diverse cultural and social context most
specifically physicians prestige, womens status, and the significance of the family. Thus the
relevance of a technology is based on the established social and cultural factors.
4


Use of IVF in the United States
A study of IVF in Nepal would not be complete without an overview of IVF research in
the United States. It is the result of numerous researches on IVF in the United States that
has led to an in-depth understanding of IVF issues. In the United States, about three and
one-half million couples in America currently experience a fertility problem (Porter and
Christopher, 1984, p.309); and overall, 6.7 million women aged 15-44 had a current fertility
problem in 1995 (Stephen and Chandra, 2000, p.134). Studies have defined infertility as the
failure to conceive after one year of regular sexual intercourse without the use of
contraceptives (Andrews et al. 1991 on Benson, 1983; Greil, Leitko, and Porter, 1988;
Higgins 1990; Hughes and Giacomini 2001; Kalmuss 1987; Matthews and Matthews, 1986b;
Pepe and Byrne 1991; Porter and Christopher, 1984 on Menning, 1980; Turner 1991; Upton
2001). While about 50-60 percent of infertile couples eventually conceive and deliver a baby,
the remaining 40-50 percent will remain infertile (Andrews et al., 1991, p.239). King (1997)
mentioned nearly 15 percent of infertile couples attempt in-vitro fertilization (IVF) or similar
treatments that cost between $8000 and $10,000 per attempt (p.10). Stephen and Chandra
indicated that the use of IVF has been fairly constant since 1988 (2000, p.132). Using 1988
National Survey of Family Growth (NSFG), they were able to point the fact that the IVF
treatment seekers are from higher economic status. Similar findings have also been reported
by other studies where use of infertility services was mostly dependent on socioeconomic
factors (Kalmuss, 1987; Henshaw and Orr, 1987). From these findings it is conclusive to say
that the use of infertility services in the United States has been limited by social class,
although the services are appropriately available.
5


Social Construction Perspective
Social construction perspective focuses on the process whereby people
continuously create, through their actions and interactions, a shared reality that is
experienced as objectively factual and subjectively meaningful (Wallace and Wolf on Berger
and Luckmann, 2006, p.285). This framework emphasized ...the way in which social
institutions and social life generally is socially produced rather than naturally given or
determined (Jary and Jary, 2005, p.565). The basis of it rested on the assumption that
...Man is a social product (Berger and Luckmann, 1966, p.58) which then followed to state
that ones reality is a result of ones social process. According to Wallace and Wolf (2006)
The heart of this theory deals with the question of how everyday reality is socially
constructed (p.286). The reality of how IVF is perceived and dealt with is also socially
constructed on a daily basis based on peoples experiences. In elucidating the social
construction of health and illness in Nepal, it is seen that Nepalese understand illnesses as a
result of internal and external influences. Here, the external influences are relationships with
ghosts, spirits, and witches and, therefore, illness is not only the sickness of the body
(Chhetri and Gurung, 1999). Health care systems are defined as ...cultural systems built out
of meaning, values, and behavioral norms (Chhetri and Gurung, 1999, p.336). In response,
the social construction of IVF is also dependent upon the various components that entail IVF
treatment and use. For instance, Birenbaum-Carmeli discussed how women, in general,
and infertile women, in particular, respond to IVF based in the manner prescribed for them by
the medical establishment and the media (2003, p.600); indicating that the reality of IVF is
based on social context in which it occurs, changing social relations, and social reality as we
6


know it. Similarly, other studies have also used social construction perspective to show that
infertility is a collective process, where negotiations between the partners and other social
and cultural influences shape ones experience of it (Greil et al. 1988; Lorber and Bandlamudi
1993; Upton 2001). In addition, reality construction is also done through use of metaphors
like chaos, limbo, life and death etc, as described by Becker (1994). Becker contended,
When life has been disrupted, this metaphoric process may facilitate action in response to
possibilities not previously contemplated (1994, p.404). Matthews and Matthews (1986b)
also discussed the social status of being involuntarily childless; again reiterating the idea that
the experience is a result of social factors rather than a medical one. They asserted that the
couples redefine themselves and have to restructure their reality through the use of medical
treatment. It is important to note here that infertility treatment like IVF involves loss of privacy
and control of ones sexual and marital relationship, requiring couples to rebuild their daily
routines. They also maintained that reality construction approach is that significant other
people are of paramount importance in defining the objective reality of ones situation
(1986b, p.645). What followed from this perception is ones way of looking at infertility is also
influenced by ones close relations.
In the 1990s, the application of IVF was expanded not only to include infertility
issues for women but for male-factor infertility as well (Birenbaum-Carmeli, 2002). This is
due to the apparentness of the situation that infertility could also be a male problem. Using
social constructive perspective, infertility was viewed as a social problem (Greil, Leitko, and
Porter 1988) where every aspect of the wives lives were affected; whereas it affected the
husbands ego since they had no control over their familys happiness. Such reactions are a
result of social construction and the roles people play in a relationship. It was distinctively
7


seen that couples tended to define infertility as a problem for wives. Lorber and Bandlamudi
(1993) showed that the burden of infertility generally tends to rest solely on females. Women
are more likely to feel openly pressured than males. Freeman, Boxer, Rickels, Tureck, and
Mastroianni in their analysis with 200 couples saw that 49 percent of the women and 15
percent of the men considered infertility as the most upsetting period in their lives (1985). In
addition, family pressures are usually greater on the women as well (Matthews and Matthews
1986b; Lorber and Bandlamudi 1993). Similar findings were also reported by Callan (1987)
who analyzed groups of 60 mothers, 36 voluntarily childless wives, and 53 infertile women
and saw that involuntarily childless women had lower levels of psychological well-being.
Thus, in general the combination of cultural pressures and mens marital power reduces the
womens ability to bargain for what she wants in the situation (Lorber and Bandlamudi 1993,
P-34).
Social and Psychological Consequences
A study by Riessman on infertile women in South India found that the meaning of
childlessness is profound (2000, p.112). Using stigma theory, she found that the stigmatized
either enforce the belief, for example use considerable self blame: There is something wrong
with me (Riessman, 2000, p.112); or use different resistance strategies like use of
transformative thoughts such as resistant thinking, which is not taking the comments
seriously or educating themselves about the infertility. The uses of various resistance
strategies are, however, dependent on one' social class, especially on how much education
one has and on the job he/she holds. What Riessman, in particular, showed was the society
8


in general reinforced the belief that being infertile was bad and that, almost in every case,
the infertile women were stigmatized. Riessman retained that the wife carried the stigma
since it is her body that does not reproduce (2000, p.121). Many women reported being
harassed through annoying comments and through repeatedly being questioned about their
family status by friends and neighbors. Callan (1987) identified that childlessness is
associated with sanctioning and stigma. Abbey, Andrews, and Halman (1992) also charged
that infertile women were frequently treated as second class citizens. However, through their
ordeals it was realized that women were resisting being stigmatized and were finding ways to
construct families in the face of childlessness.
Starting from the initial stage of knowing that one is infertile, to undergoing IVF
treatment, stress has been identified as a major result of such process (Andrews, Abbey and
Halman, 1991; Hughes and Giacomini 2001; Pepe and Byrne, 1991; Lorber and Bandlamudi,
1993; Menning 1977). A study by Andrews et al. (1991) found that stress associated with
inability to have children affected ones marriage and quality of life, most specifically, infertility
stress led to marital conflict, and decrease in sexual self-esteem, satisfaction with ones own
sexual performance, and frequency of sexual intercourse. Menning, by taking parallels from
the devastating effects of Nazi concentration camps, talked about how males and females
during that period had reproduction problems and was one of the first documented works on
the effects of stress on male and female reproduction (1977). Pepe and Byrne (1991)
concluded that infertility treatment significantly affected marital and sexual satisfaction for
couples during and after treatment. Other stresses related to quality of life are decreased
evaluations of life as a whole, self-efficacy, marriage, intimacy and health. A study by Abbey
et al., (1992) showed that fertility stress exerted negative effect on ones life quality via its
9


effects on self-esteem, internal control, and interpersonal conflict. By examining 185 married
infertile couples, they were able to analyze the relationship between infertility and subjective
well-being. One aspect of infertility that is hard to cope with is the uncertainty of ever having
a child. As a result, individuals are said to undergo a number of progressive stages of
realization. Menning (1980) pointed out infertility as a state of crisis for couples, which
involved going through a series of stages that included surprise, denial, anger, isolation, guilt,
grief, and resolution. Matthews and Matthews (1986a) have also used similar socio-
emotional responses used by Menning to infertility. These studies focused on the verity that
before resolution occurs, various emotions such as- victims blaming themselves, being
potentially stigmatized, and occurrence of loss of locus of control over their lives etc; are
experienced by individuals.
As already declared, one of the common stresses also identified by a plethora of
researchers is the sense of loss of control (Abbey et al., 1992; Callan, 1987; Matthews and
Matthews, 1986b; Porter and Christopher, 1973). According to Abbey et al. control refers to
individuals beliefs about who or what determines outcomes in their lives" (1992, p.409);
meaning that people need a sense of having an internal control over their lives. When
individuals find out they are unable to procreate or do not have an internal control over their
body, they experience a negative effect on their performance and life satisfaction. As a
result, couples are more likely to experience anger, depression, guilt, frustration, anxiety,
isolation, and numerous other psychological problems. Callan (1987), specifically, discussed
the reason for experiencing loss of control as the fact that people typically view their fertility
behavior as something they have control over. In Callans words, Lacking control over their
lives, they are frustrated because they can neither experience parenthood nor fully pursue
10


alternative sources of satisfaction" (1987, p.848). In the case of infertility and reality
construction, Matthews and Matthews stated, infertility directly challenges the social function
of marriage (1986b, p.643). Porter and Christopher quoting Veevers (1973) stated, wanting
and having children are natural and normal behaviors, which constitute religious and civic
moral responsibilies, and which reflect sexual competence; Children are defined as the
meaning of marriage (309). With the sense of loss of control and change in ones perception
of one's reality as a result of this loss, many couples are seen redefining their reality by
believing that is a curse or punishment by God (Menning 1977, p.108-109); or in other words
they seek answers to their problems outside their realms of control i.e. the supernatural.
Cultural Pressures
In addition to having tremendous social and psychological pain, there are further
pressures exerted from the existing cultural norms. Hughes and Giacomini mentioned that
such frustration comes ...from broader cultural, social or economic imperative to procreate:
this suffering is a product of a prenatal society, which values women largely for their ability to
bear children (2001, p.436). Hughes and Giacomini also maintained that there is tension for
women seeking treatment since IVF challenges their status (2001). The biggest pressure is
usually on the wife and is mainly exerted by the husbands family. A study by Axinn (1992) in
Nepal on fertility behavior indicated that husbands have a good deal of say in fertility
decisions, and hence their (husbands) experience influences wifes fertility decision. The
fact that Nepalese society is a patriarchal society; it gives men the power to make all the
major decisions in the family. The importance of the husbands say in a relationship also
comes from the underlying fact for preference for sons i.e. males. Sons are seen as the
11


bearers of the family name, performers of funeral rites, as well as providers of support in old
age. Thus, they have a higher status in the society. As a result of such status, men
generally have the say on fertility issues. Studies have shown that sex preference
specifically for sons, influences fertility decisions in Nepal either through discouraging women
from practicing contraception until they have a son or by stopping ones fertility after the birth
of the male child (Tiziana, Matthews, and Zuanna, 2003; Stash, 1996). The preference of
sons by the Nepalese mainly for socioeconomic and religious reasons (Karki, 1988); placed
the added pressure of not only having a child but having a child with the right sex, which in
this case is male.
Ethical Issues
In addition to dealing with stigma, stress, and loss of control, infertile couples also
have to face the ethical and moral issues involving IVF. Hughes and Giacomini (2001)
mentioned that to have a healthy child, subfertile couples may accept a 20% risk of death
and give up 29% of their income (p.432). Therefore there are risks involving safety, cost,
and effectiveness of the procedure not to mention other ethical implications. According to
Zimmerman, ...in vitro fertilization is the most controversial, involves the greatest risk and
raises the most questions concerning commonly held notions of family and family
relationships... (1982, p.233). Some of ethical issues raised in Zimmermans research were-
effectiveness of the procedure, here it was thought as playing games of chance with life;
paternity issues since it is common to mix donors semen; and legitimacy of the child. In the
context for Nepal, these matters become even more multifarious due to prevalent cultural and
12


religious beliefs. Judith Modells (1989) study on how parenthood is perceived in an IVF
program revealed, IVF upholds cultural values about the family, sexuality, and the proper
relationship between parents and child (p.135). Parents were more willing to adopt if IVF
failed than through sperm donation or surrogacy. In Modells words, they want either all or
no biological continuity with a child(1989, p.134).
Nonetheless, in the light of such emotional dilemma faced by couples, it seems that
IVF gives couples some glimpse of hope in the midst of pandemonium. While some studies
have shown that the success rate for IVF is estimated between 20-25 percent with extremely
high failure rates (Porter and Christopher, 1989); other studies have shown the success rate
to be about 5-10 percent (King and Meyers 1997 on Arditti, Kelin, and Minden 1989), in any
case IVF procedure is an available option. Callan (1987) in a study on 53 infertile women
who were attempting to have a child on IVF program reported having better and closer
marital relationships in the long run. Callan contended, Several years of sharing the crisis of
infertility may explain their closeness (1987, p.849). Sabatelli, Meth, and Gavazzi (1988)
found that despite infertility, there was no overall decline in the couples marital satisfaction.
In fact more than 50 percent of the respondents reported an increase in emotional support.
Lorber and Bandlamudi (1993) have also accounted the fact that undergoing IVF treatment
helped build stable marriages. These findings reiterate that although IVF may not be fully
fool proof, it is buying couples time to overcome the initial adjustments of being infertile.
13


External Support: Role of Doctors and Medical Professionals
Studies involving IVF treatment also emphasized interactions with medical
professionals and how that can affect ones outcome of treatment. Physicians lack of
attentiveness to the emotional aspect of fertility was thought of as affecting treatment (Greil et
al., 1988). It was seen that particularly more attention was given to the females than males.
The study accentuated on the issue that treatment should be couple oriented and that
physicians need to be careful about treatment and other recommendations since physicians
help to shape the couples interpretations of their infertility (Greil et al.,1988, p.174).
Matthews and Matthews (1986a) have also drawn attention to couple centered treatment with
emphasis on social psychological issues by family practitioners, since according to them,
involuntary childlessness is such a sensitive couple-related phenomenon (p.485). Porter
and Christopher (1984) discussed how coping patterns about being infertile start with
depression and mourning, to accepting the outcome and planning for the future. They
stressed on the importance of how family life practitioners played a major role in helping
couples deal with this crisis. Their study centered on providing counseling treatment and
spreading knowledge about infertility issues with an emphasis on resolving emotional conflict
and pointing out possible options. Other suggestions used were being aware of the impact of
infertility treatment on marital, sexual, and family issues; encouraging clients to develop open
lines of communication; being aware of support programs and groups for the infertile couple
(Pepe and Byrne, 1991, p.308). Another notable suggestion made by Higgins (1990) was
giving couples as much control as possible by the doctors, which may include either
supporting or terminating treatment. A comparable study by Tain and Robertson (2002) also
I
t
14


indicated that it is the physician, in collaboration with the patients, who may influence couples
unduly or relieve them of making painful decisions. This study also analyzed the intricate
relationship between medical professionals and the patients in their process of undergoing
IVF. The importance of combined influence and time constraints for IVF procedure stand out
as the two pertinent issues. Tain and Robertson stressed the notion that doctors and
patients are drawn into this professional pursuit of success (2002, p.388); designating that
both parties need to be committed to the process regardless of the outcome or the time
constraints. Mennings stated that crisis intervention by a caring professional may make all
the difference (1980, p.314); she stressed on developing a plan of investigation and
treatment with couples, where couples are worked with instead of worked on.
Therefore an important aspect regarding IVF treatment is having caring physicians
and medical professionals. The effect of IVF treatment on patients mental psychology is
vital. Andrews et al. (1991) suggested that many times the cause for couples infertility is due
to psychological problems; they mentioned that research currently estimates that less than 5
percent of infertility is caused by emotional problems. Matthews and Matthews (1986a) also
discussed the occurrence of negative images found on infertile women. Borrowing from Platt,
Ficher, and Silver, 1973, they stated, infertile women are said to manifest high degree of
anxiety...higher neuroticism, lower succorance scores, and higher scores for emotional
disturbance (p.480). Other studies have also indicated that women with functional
reproductive disorder also primarily are emotionally disturbed (Matthews and Matthews
1986a on Mandy and Mandy 1958, p.480). Higgins (1990) discussed similar possibilities; in
other words, he mentioned the potential for emotional stress leading to fertility problems.
Bar-Hava, Azam, Yovel, Lessing, Amit, Abramov, Militscher, and Chen (2001) additionally
15


showed that following stress from infertility clearly puts strain on couples sexual relationship,
resulting in interference with the process of conception. With the sample of 96 women
enrolled in an IVF program, it was seen that positive reinterpretation and active coping were
positively associated with sexual functioning leading to successful IVF treatment. Although
studies have not conclusively shown the relationship between ones psychology and infertility,
they acknowledge its existence. Therefore, it is imperative to have effective treatment from
health care professionals that not only treat the biological aspect of infertility, but the
psychological and social piece of it as well.
Despite the complex characteristics of IVF, its spread and success has been
tremendous in the United States. What is more surprising is the long-term outcome it has
produced. Studies by Gibson and Ungerer (2000); Golombok, MacCallum, and Goodman
(2001), have found that IVF children were functioning well and did not differ from other
normally conceived children on any of the assessments of social or emotional adjustment.
What was also identified were indications of a superior parental nurturing that resulted in a
better development of children emotionally and psychologically (Balen, 1998). This, then,
brings the positive social impact this process has been able to make to light.
In sum, based on all the research done so far on IVF what seemed to emerge is the
complexity and multilayered vicissitudes of IVF. Just as a society is a cluster of many social
components, so is the process of IVF. The present study attempted to explore this aspect of
IVF by analyzing its introduction in OM hospital and research center in Kathmandu, Nepal.
16


CHAPTER 3
METHODS
Procedure and Sample
This study was conducted at the OM Hospital and Research Center in Kathmandu,
Nepal, which is the hospital where IVF was introduced. The study population, therefore,
included individuals involved in the IVF procedure which in this case were doctors, patients,
nurses, and doctors assistants. The data reported were collected through questionnaires
and in-depth interviews that were carried out from December 2006 to January 2007, either
through face-to-face or phone interviews. Due to the differences in peoples educational
background, some of the questionnaires were handed out to the respondents before the
interview and some were filled out with the interviewers help during the time of the interview
along with the consent form. Consent for the interviews through phone was audio-taped.
Both the questionnaire and the interview guideline were used as question guideline during
the interviews. The sample was obtained based on convenience sampling method. Some of
the respondents were initially contacted by a key informant who was a doctor working at the
IVF center at OM Hospital. For the interviews conducted by phone, the key informant
contacted the patients to set up a time for the interview. The times for the interviews varied
greatly from 20 minutes to an hour, since it was based on the respondents availability and
their comfort level in discussing their experiences.
17


The total sample population consisted of 22 individuals, out of which 18 were females
and 4 were males. The sample was divided into the patient population and medical staff.
Among the patients who participated, 85% were females and 15% were males. The age
range for patients were 29 to 45 years (mean = 38.31). The educational level varied among
patients with 23% having educational level less than high school, 15% who had high school
education, 46% had bachelors, 8% had masters, and 8% had some sort of certification. The
patient sample was predominantly middle class to working class individuals. About 54% of
the sample had income less than Rs. 50,000 ($641.00) and about 46% had income over Rs.
50,000 ($641.00). The majority of the patient populations, about 69%, were unemployed
while about 31% were employed. All the patients were Hindus. The average years of
marriage was over 5 years with a range from 5.5 years to 32 years (mean = 17.46) with
average age of marriage ranging from 13-32 years (mean = 21.77). Also, about 69% of
sample had been attempting to get pregnant for over 5 years, while 31 % had been attempting
for less than 5 years. Out of that sample, 46% had female factor infertility, 15% had male
factor infertility, 8% had female and male factor infertility, and 31% were unaware of their
infertility status since their reports had been normal and no infertility problem was identified.
About 69% of the sample had no children, while 31% had at least one child. The average
number of IVF treatment undergone by patients was about 2 times within a period of about
less than a year, to at least 5 years.
Among the medical staff who participated, 89% were females and 11% were males.
The age range for the medical staff were 23 to 58 years (mean = 35.55). The educational
level varied with 22% who had high school education, 22% had bachelors, 44% had masters,
and 12% had some sort of certification. About 56% of the sample had income less than Rs.
18


10,000.00 ($128), 11% had income of about Rs. 40,000.00-50,000.00 ($577), and about 33%
had income over Rs. 50,000.00 ($641). A majority of the medical staff was employed full
time (89%) and others were part time (11%). About 89% identified themselves as Hindus
and 11% as other than Hindu. In addition, about 22% were single, 67% were married, and
11% widowed, with 78% having at least one child and 22% with no children.
The interviews were conducted on the hospital premises depending upon where the
respondents felt comfortable; this included clinics, operation theatres, cafeteria, hospital
rooms, and the waiting areas. The interviews were conducted in Nepali, Hindi, and English.
The interviews addressed issues of what led to IVF treatment, respondents feelings, beliefs
and experiences with IVF and infertility. The questions were mostly drawn from previous and
current research on infertility and IVF. In order to gain a better idea of how people looked at
infertility and IVF treatment, open and closed-ended questions were asked. Couples were
interviewed together since respondents seemed more comfortable answering the questions
together. During the interview, extensive probing was done to clarify responses especially
information dealing with their emotional reactions and feelings. In addition, same questions
were asked in two or three different ways to clarify the question. During the interview, the
respondents were encouraged to give their account of their experience since culturally it is
considered rude for women to be explicit about their feelings. The interviews were audio-
taped, transcribed verbatim, and those in Nepali and Hindi were translated.
The data were coded first by using categories from the questionnaire such as age,
sex, marital status, length of time undergoing IVF treatment etc. Initial coding was done
through open coding, evaluating the data line by line forming segments and through the use
of memo writing. Each segment was then coded. Further categories were produced through
19


identification of themes in the data. Once the themes were developed with integrating
literature that fits and discarding data that did not, specific categories were created.
It is important to note here that due to the presence of two major groups- the patients
and the medical staff; there was a large difference in peoples views about IVF. Despite such
differences, the richness of respondents answers was not affected; each individual was able
to give an account of his/her experience. What was interesting, however, was that people's
experiences between the two major groups were vastly varied; the medical staff was
particularly able to understand the view of the patients, while the patients did not seem to
have the same view point as the medical staff on infertility issues such as adoption. It is also
critical to note here that the data suffered from some drawbacks because of cultural
differences in terms of peoples experiences and responses, and a degree of caution is
required when attempting to deduce and generalize the findings.
20


CHAPTER 4
FINDINGS
Social and Cultural Pressures
Family, Cultural, and Societal Pressures
In Nepal, a woman's status is based on her being a mother. After marriage, her
position in the family and status in the society is maintained by her being able to produce an
heir. Sustaining that position is of upmost importance to women. Since a majority of women
in the study were housewives, their motherhood status was more crucial to them. About 84
percent of the women said they thought about their infertility at least two to three times a day.
A 29-year-old patient said, It wasnt how many times; I thought about it all the time Life
without children for them was a curse. Its as God has punished them said a 34-year-old
female gynecologist. Without children, women were treated as social outcastes and were
labeled in a negative way. If she doesnt have a child, that lady is thrown out of her house or
is taken as a very bad sign in the society; they dont like to see her face! is what a male
gynecologist described the shunning that women endured. A 44-year old mother of two
reported the time when she was infertile as being one of the hardest times in her marriage.
Her family would constantly taunt her about her infertility. She said, Everyone from my
husbands family used to say things to me...that I dont have a child and that no one will know
even if I die; they would say things like that! Women were additionally questioned about their
21


family status outside the home, which added further pressure on them. Constant questioning
about ones marital status was a cultural norm. As a 29-year-old housewife who has a
master degree in finance described, You can see it in their eyes, without even saying a word
I can feel their negative vibes...I feel very helpless during those times. Women who had
accepted their fate as being childless were looked upon negatively. As a 38-year-old, well
educated woman with a degree in history described: I personally did not think about infertility
as much, but when people in the house would say that I dont try treatment; like my family
would say, people all over the world seek so much treatment and you dont, then I would
think about it...otherwise I would never think about seeking treatment. She also mentioned
that there was additional pressure for her to get pregnant since there were no male children
in the family. Family pressure hence played an important role in womens decision to seek
treatment. Infertile or childless women were seen to be inauspicious, as defined by a 39-
year-old housewife that she is cursed. The strong cultural belief about having children was
elaborated by a 32-year old nurse, ...there are beliefs among Nepalese people, such as if
they dont have a child, they wont go to heaven, the doors to heaven will not open...So we
have beliefs like that... So cultural practices played a major role in defining what infertility
meant in this group.
Remarriage
Another major problem that women encountered from their families was the topic of
remarriage. Seeing that the women were unable to reproduce, many families suggested the
22


men to remarry despite the fact that some of the infertility problems were male related. A 32-
year-old female nurse declared For instance, say the son has low sperm count, they will still
blame the daughter-in-law, thats how Nepali society is! Despite knowing that its his problem,
they might get him married elsewhere since they think this daughter-in-law obviously cannot
reproduce. Such episodes of family pressure were also stated by a 34-year-old female
gynecologist:
I think when the men have problems they want to hide it because others will label
them. Its especially hard for the men who are the only son in the family since they
need to carry on their family name...also we have the tradition to blame women, and
we also have the tradition of remarrying if the current wife cant reproduce. So they
would try treatment a couple of times. After that theyd say its enough and that its time
to remarry the man. So the parents brain-wash the son into getting married the second
time.
The Burden of Infertility
Due to the issue of remarriage by the husbands, the wives seemed to be pressured
more about their infertility. The burden of infertility definitely seemed to rest on the female
(Lorber and Bandlamudi, 1993). Having children was looked upon as the most important
aspect in womens lives. Many women, unable to have children, expressed a feeling of
desperation and were blaming themselves about their infertility status. A 42-year old
housewife described, I felt it especially in the social circles; I would feel that I should have
been able to give my husband a child. I felt like I let my family down...I always felt that there
was something wrong with me... Women were also concerned that they ruined their
husbands life and some were more than willing to have their husbands remarry, such as a
38-year old housewife stated If my husbands decides to remarry, I shall fully support him...if
23


he wants someone else, then Im not going to be sad...I won't have any ill feeling towards
him...I will tell him to be happy. Although many women were self-blaming about their
infertility, they did not feel a sense of loss of control. When asked if they felt a loss of control,
a 38-year old architect answered, Not really. We want to have children but its not
something that we could not live without. Also, I have my work. I guess thats how I deal with
the problem. Another 38-year old patient stated, In terms of being able to have a child, I still
feel like I have control over my life...Ive never felt like this is my fault and that it happened
because of me...I don't feel any kind of guilt.
As the predominant family structure in Nepal is extended-family, intimate ties among
family members are crucial. As a result of a well-knit family structure the support of every
member is important. The value of family was reflected in the fact that when asked, how
having a child would change ones life; about two-thirds of the women replied that they would
be accepted as a part of the family again. A couple who had been trying to have children for
the last eleven years mentioned that they would be accepted back into the society, once they
have children. A 32-year-old housewife on the issue of acceptance expressed:
I would be invited to parties and other auspicious occasions. I would get a
chance to be a part of the family, everyone would like me and that would give me
happiness...I dont go to parties that are organized by my husbands family because
theyll invite us but you can see that we are not welcome.
A 44-year-old mother of two acknowledged Yes, its important to have children in the
family because it spreads happiness, there's someone to continue the family name, to carry
our name. The importance of having a child in Nepalese families can be reflected by the fact
that a 45-year-old housewife underwent IVF treatment not due to infertility reasons but
because her only son was dead. Due to the constant questioning of her family status and the
shunning that the family from the husband side imparted upon her, she underwent treatment
!
24


just three months after her sons death. On asking if she felt lonely or isolated after the death
of her son, she answered, Right after I did, but now, since Ive come to the hospital, Ive
forgotten...I have to forget, I have to hope that I will have another child. This statement
clearly exemplifies the pressure on her to conceive again.
In addition to the patients, the medical staff also clearly identified family, cultural, and
societal pressures as affecting one's status. The gynecologists specifically mentioned that
mothers-in-law would come to the clinic asking why their daughters-in-law, who have been
recently married, havent gotten pregnant. Inability to get pregnant right after marriage was
looked upon as theres something wrong with them, contended a senior gynecologist, its a
social stigma. She also mentioned that women are desperate to have children because they
want to conform to society. She said, they are actually more fearful of society...Ive yet to
see...people whore not able to get pregnant and tell their in-laws thats its a choice...so its
society that pressurizes them...not their own need, want of a child. It thus is apparent that
having children then does not become a choice but is the norm. In abiding to the norms,
women undergo IVF as they are expected to be actively engaged in doing something about
their infertility status.
Faith or Science?
IVF treatment at OM hospital is vastly different from the treatment given in developed
countries. The treatment at OM hospital is carried out in batches. What this means is IVF
procedure is resumed every 45 to 60 days where patients are collectively stimulated (in
25


groups of about 20) at the same time. This protocol is followed because it helps in the
efficient use of the medication and is cost effective for the hospital. Based on the total 14
batches that the center has performed from July 10th 2004 to October 16th 2006, the success
rate of the treatment varied from 52 percent being the highest rate of pregnancy to 25
percent, which is the lowest rate of pregnancy per batch (APPENDIX C). Although there are
a numerous factors that affected the rate of pregnancy, in the context of people experiences,
faith played a major role in ones outcome of IVF. For many, there seemed no clear
distinction between faith and medicine. Ones faith in God and faith in the IVF treatment went
hand in hand; one did not exist without the other. Almost everyone identified the importance
of having faith or a belief system while undergoing IVF. This form of faith seemed to give
individuals hope, spiritual support, and a sense of peace as defined by patients, and also
gave them the strength to stay positive. Having a belief system appeared to give patients the
strength to deal with their infertility. A 38-year-old patient articulated:
I have a strong belief in god, I always say, if someone needs to go to get
somewhere like say the bus station and if he thinks hes going to miss the bus; then he
will return half way. If he is determined to reach where he needs to go, then he
will...everything in life is like that...if its written in the stars it will happen. If Im meant
to have children, I will. If its not written for me then it wont. No truth can change that. I
have to be strong and have faith otherwise people, the society, will not let me live
peacefully.
As one patient described, I have most faith in Lord Shiva...if you have faith, things
will happen...good things will happen eventually. On asking what she thought about IVF, a
41-year-old patient expressed I feel IVF is a medium, however God has to bless us...he has
to grace us....Just by seeking IVF treatment, I do not believe it will help me get
pregnant...God has to bless us as well. What was surprising was every patient had a
positive outlook regardless of the number of treatments they had undergone; Peoples faith or
26


belief in God was the cause for their optimistic outlook. It appeared that every time they
underwent treatment, they were hopeful. As a 38-year-old patient articulated ...all we can
do is hope and pray...we have gone to every temple possible and have shown all the
priests...they say it will happen and we have to believe that right? It thus seemed that having
faith in God was equally if not more important than the IVF procedure itself. In fact, as a
result of the success of the procedure many also conveyed how their belief in God became
stronger. A 42-year-old patients stated because of this ordeal my faith in God became even
stronger...I still take the time out to worship and pray." Yet another 44-year-old mother of
two, shared her condition when she was childless, she said, I use to cry, I would go to the
temple of Lord Durga and tell her, its up to her to give me a child and things would be
fine...my in-laws were cruel to me and I used to tell them this time it will happen...I have full
faith in God."
Superstitious/Religious Practices
Besides having strong belief in God, Nepalese culture is also enshrouded with
religious practices of predicting ones destiny or showing ones birth chart to the priest, who is
presumed to have mystical powers that can change the course of ones future. This is
because illness is considered to be a result of external influences, which are relationship to
spirits and mystics, and one's biology (Chhetri & Gurung, 1999). As a gynecologist defined,
Patients say that God has punished them, they think since they havent done anything
wrong; they go to all the traditional witch doctors or the priests, or try and perform rituals, to
27


make it right. Although not as common today, the practices of going to witch doctors,
psychics, or performing rituals are still being carried out. So strong were patients beliefs that
some scheduled IVF treatment around what were considered as auspicious days. Some of
the rituals mentioned by patients included drinking blood of different animals or going to
different temples or constant praying, as a way to get pregnant. Some of the patients were
also hospitalized from reactions to the herbal medicine they were taking to get pregnant. On
asking a 38-year-old architect on how supportive her family has been, her reply was, We
have been trying long and it's difficult but my families from both the sides are extremely
supportive. They believe in God and have gone to the priest several times. The priest has
said that we will have children surely this time and I feel that way too. As cited from this
example, having faith in the supernatural gives the patient hope that the outcome will be
successful. Having such belief is extremely important in undergoing this type of treatment
where there is no guarantee in regard to the outcome. As a 41-year old gynecologist
explained on the topic having faith, ... thats very important in our society, in such a culture
you know...I tell patients who are frustrated to remember whichever God they
worship...having faith helps them. Another gynecologist on the topic of faith made an
extremely pertinent point ...if IVF does fail, then they have their faith or their beliefs or their
religion or their Gods to fall upon. They can either blame the Gods for not giving them the
children or blame their fate. So they have something to relate to instead of blaming
themselves. She goes to add the importance of having a belief system for the medical staff
as well, she contented:
Again we fall on fate. We tell the patients were giving you our best, the outcome is not
going to be a hundred percent...the babys made, it can go into the uterus it may not
take and that again...the failure of the pregnancy not taking, not embedding; when that
28


happens, then fate or destiny or religion is what we fall upon to say, ok, its wasnt
meant to be, weve done our best.
While some individuals had strong faith in the supernatural as well as in God, others
were skeptical about the effectiveness of such practices; as a 29-year-old mother stated, Its
not good to overdo it because if the outcome is not good then it makes you mad at God!
This view of being skeptical was stronger among the medical staff than the patients.
Nonetheless the importance of having such a belief was acknowledged even by the
individuals who were not fully supportive of it, as exemplified in the following conversation
with a patient:
Interviewer: How much worshipping and carrying out of rituals did you perform?
Respondent: Worshipping...not that much. I would remember God in my heart and
thats all. Im not the type to perform rituals and go to the temple. Gods
in my heart and that's how I pray, that's all. I however did go to the
temples, when I was undergoing IVF treatment.
Interviewer: How much did that help, did it give you inner-peace; did going to the
temples help you or it didnt make that much of a difference?
Respondent: God is something one has to have faith in, and because of him I have a
child. It is because of God and also because of everyones support that it
has been possible.
Another example (with a medical staff) being:
Interviewer: What do you personally think about going to the temple or seeing the
priest for getting pregnant?
Respondent: Some are very superstitious about God. For me, I do believe in God but
on a personal level I think, if Im a good person, then good things will
happen. Also, because Im a Hindu, I was raised with such beliefs, I know
God exists, but I havent gone to the extreme. I can pray to God but I
have to know how to do my job well...there is God's support but its not
90 percent, maybe just 50 percent...
Interviewer: How important is having faith in God especially for patients?
Respondent: Yes, thats there. I would say 50 percent...there are some who come to
the hospital only after making sure its auspicious to do so...so some are
extremely superstitious and thats their belief system, their hope, so it
depends...
29


Husbands Support
In addition to the support system that faith and religious practices brought, another
strong support for patients were their husbands. Couples experiences of IVF were mostly
defined by the husbands. Having the backing of the husband was extremely important. In
addition to facilitating financial assistance, husbands support also defined how the woman
would be treated in the family. A 38-year -old women insisted my husband does not care
about this issue too much, so people dont bother us. About less than quarter of the patients
mentioned having no support from the husbands side of the family, and were ill-treated
through constant taunting and questioning. However with the support of the husband, they
were able to ignore the comments and focus on the treatment. As a 42-year-old mother of
two described, Through others experiences, such as- some had unsupportive husbands
or...the husband was going to remarry...I didnt have to go through that...since my husband
was supportive... She goes on to express ...having the support of my husband I never felt
like it was my mistake... Another 30-year-old housewife who has trying to get pregnant for
the last 15 years responded to the interviewers questions:
Interviewer: How do you cope then...how do you deal with the comments?
Respondent: I dont have any coping strategies, I just let them talk. The only person
that I can pour my heart out to is my husband.
Interviewer: What does he say?
Respondent: He says that I should let them talk; it makes no differences to us.
Actually he cant say anything either...my husband tells me to just listen
and forget about it.
Despite the fact that the husbands, in a majority of cases, were supportive, it is also important
to note that the husbands had the most say in the treatment as well. In acknowledging their
husbands presence, the wives also seemed to express their gratitude towards them. As a
30


44-year-old mother who conceived as a result of IVF said, Hes done a lot for me; Im in debt
to him. When letting her know that she too has played a key role in this, she answered,
Without him I couldnt have the child that is what I know, so he has given me a lot of
support. This conversation is a reflection of the patriarchal perception of the society where
the man is regarded with upmost respect. Another area where the males dominance was
also seen was during the interviews with the couples; when the male was around, most of the
women stopped talking. An example of such dominance was seen during an interview where
the patient stopped talking when her brother walked into the room. It is cultural to let the man
talk since he is assumed to know more. Such behavior was not only apparent during the
interviews but also during their visits to the doctors, where the husband would describe to the
doctor the problem the wife was having. The continuation or discontinuation of ones
treatment was also in most cases decided by the husband. In asking about other options
such as seeking adoption, a 45-year-old housewife affirmed, I will need my husbands
consent for that, on inquiring her about further treatment, she replied, I cant make the
decision, it will depend upon what he says... Such responses were not only heard from the
patients but the doctors acknowledged the upper hand husbands have as well. On inquiring
who usually makes the decision for treatment, a gynecologist responded, In Nepal its
definitely the man! Most of the time its the man who decides... On further questioning about
other family pressures the gynecologist reported:
In IVF its usually the husband because theres such a lot of money involved and
its much cheaper to get the man remarried...its a very male dominated society, most
families would say its easier to get the man remarried, youll get a new dowry, you get
a new wife, maybe you have more chances of pregnancy.
So its the husband who has to be really supportive...
31


Therefore one can see that men frequently have the upper hand, since they have
more bargaining power than women (Lorber and Bandlamudi, 1993, p.33) and it is the
women who takes the burden of his infertility (Lorber and Bandlamudi, 1993, p.34).
Fortunately all of the respondents said that their relationship with their husbands were
excellent before and after undergoing IVF and that that support led them to seek treatment
despite oppositions from the family or the society.
Difficulties in IVF
From the initial stages of the introduction of IVF in Kathmandu, to the present;
educating the public has been a major endeavor the hospital has been undertaking. The
hospital has numerous media coverage such as television and radio shows that explain to the
public what IVF or test-tube baby procedure entails. Although peoples perception and
acceptance of IVF is based on their educational level, now many seem to have a better
knowledge of IVF than before. Therefore, the efforts to educate the public have been
somewhat fruitful. In fact, the male gynecologist, who introduced this process, has also
produced several movies dealing with infertility to educate people about infertility issues in
the hope that it can increase awareness among the people. As a 50-year-old gynecologist
affirmed the increase in public awareness of IVF:
Of course weve been trying to educate the public and say its only the fertilization
that is done outside...so the baby actually grows inside you, youre the one whos
nurturing the baby. So that is the first bonding that occurs between the mother and
child. So this is a very pertinent point where a lot of patients do know that theyre
getting donated embryo but because that baby has been fed and has been nurtured by
32


her, so she actually bonds better with that child than you know, an adopted child. So
this is one of the arguments for IVF and not for adoption.
IVF as a Form of Stigma
Despites endeavors to educate the local population, it appears only the patients who
do undergo the treatment are aware of the procedure. Considering the fact that the overall
literacy rate of Nepal stands at 50.7 percent, many do not have the means or the time to
educate themselves about IVF. A large amount of the population is misinformed about the
treatment. As one of the doctors assistant stated, Societys understanding of IVF is getting
pregnant without the husbands semen...which is using someone else's, thats what they
think. While some tend to think IVF means not having your own child as described by a
medical lab technician. Others believe, IVF means the baby is born in a test tube! or test-
tube baby is grown in the test-tube...not inside the mothers womb as described by two
female two gynecologists. Some patients, as a result of spending money assume that the
treatment is 100 percent successful, Many dont understand stated a 26-year-old lab
technician. Many who come seeking for treatment are not as educated, and consequently
there is some stigma attached to IVF, such as the procedure is artificial or harmful to patients.
Changing this belief system will definitely require more education among the population about
the benefits of IVF and to remove the stigma that is attached to the procedure and the patient
who sought treatment. Due to the stigma that is attached with IVF, many patients choose not
to tell their families about seeking treatment. The use of such isolation or secrecy could also
be To protect themselves from evaluations by others (Matthews and Matthews, 1986a). On
asking the 38-year-old patient why she chose not to disclose her treatment to her family she
33


said, ...because people have so many questions... Another medical staff verbalized ...the
mother-in-law and other relatives are most against it because they dont understand and they
dont want treatment, they are afraid of seeking treatment. Another reason many decided to
keep the treatment a secret, as explained by a 34-year-old gynecologist: I think its the
society, theyre worried about what others think... since there is some negative connotation
attached to the concept of IVF. A 42-year-old mother of two, communicated that doctors and
the medical staff should not devaluate the procedure since people might misinterpret what
IVF is. She stated, IVF is not something that is bad or should be looked upon badly...but
that is the concept people have here of IVF... and educated people should not talk negatively
about the IVF, they need to clear things out. The patient thus gave the impression that
doctors and the medical staff need to be more serious about explaining the procedure to the
patients rather than ridiculing them (the patients) for their lack of understanding.
Egg-sharing
In a culture that is so adamant on having ones biological children, there were very
few objections to the idea of egg-sharing. A majority of the women undergoing IVF
particularly had tubal blockage and consequently harvesting fertile eggs was a problem in
patients. Therefore, the procedure involved egg-sharing of those individuals who could not
produce fertile eggs. Many patients however had no objection to egg-sharing. As a 50-year-
old female gynecologist explained, we dont have a lot of problem about egg-sharing
because the population that comes to us is actually the older generation. Most of them are in
34


their 40s, so they know...they may not be able to produce, harvest good eggs. A 26-year-
old female medical lab technician also stated, I think most of the families are not like
that...most of them say its ok on egg-sharing... Women seemed to have suffered so much
societal pressure, that egg-sharing became least of their problems. Thus, egg-sharing or
using donor eggs appeared to be an accepted idea. On the topic of egg-sharing a 29-year
old patient acknowledged, Im supportive of IVF because I was able to have my daughter
through the treatment...so I dont have any negative comments on it. This patient however
also acknowledged that no one from her husbands side of the family knew that she
underwent IVF. This again indicated the stigma attached to IVF; that people preferred not to
tell their families about undergoing treatment.
Patients also requested to match the donors caste to the receivers caste in order to
match the babys features and color to the patients characteristics. A 50-year-old female
gynecologist affirmed we always try to match their caste. When we do, we keep in mind that
somebody is a different caste or different color. A 34-year-old female gynecologist also
attended to the notion that they try not to entertain such demands since they cannot
guarantee that they can find a donor that matches the recipient. These requests therefore
were made to match the physical features of the child to the parent, and not for cultural or
religious purposes.
For the reason that IVF treatment may involve egg-sharing, people do not want to
disclose the fact that they underwent the procedure. People do not want to loose face or be
looked at in a negative way. Therefore, there is both support and opposition against IVF
which mainly has resulted from lack of knowledge and education among the population.
35


Stigmatizing IVF definitely has stopped many from getting the treatment that could probably
be beneficial.
Financial Burden
In addition to the stigma attached to IVF and issues with egg-sharing, another
pertinent problem that patients faced is the financial costs that are related to undergoing IVF.
Medical representatives and patients alike expressed difficulties regarding cost of IVF. A
majority of the patients who do come for treatment at the OM center are middle to lower class
families, and therefore are not able to afford treatment. On an average the treatment costs
about Rs. 200,000.00 to Rs. 250,000.00 ($2500-$3000), which is some patients life long
savings as indicated by a female gynecologist. Another gynecologist mentioned that most
families earn about Rs. 5000.00 to 10,000.00 ($64-$128) a month in the urban areas and the
amount decreases even further in the rural areas; making treatment unaffordable to many.
However the social pressures to have children is so much that ...many sell their land or their
house and are determined to get the procedure done... asserted a 26-year-old lab
technician. Although the treatment is cheaper in comparison to the costs elsewhere, even
that amount Nepalese cant afford affirmed a patient. Therefore, financial cost seemed to be
the main issue that determined whether patients would seek treatment.
Another significant problem that was identified was the time required to undergo
treatment, and the fact that the outcome was unknown. Many patients from the beginning
wanted to know their chances, so that they could decide whether they still wanted to seek
36


treatment. However this was something that the doctors could not guarantee. A 50-year-old
gynecologist clarified the struggle patients are in involved in:
Its the time they have to devote. They have to come every morning once we
start stimulating and to get their injections. So its quite time consuming and once they
undergo that whole twenty days or whatever schedule; right from the beginning-from
preparation to the time we transfer the embryo, theres always this fear that all this
would be in vain. So this is the biggest problem they have.
Alternative to IVF: Adoption?
Despite the fact that successful IVF outcome was not guaranteed, patients were
more willing to undergo treatment than to seek other options such as adoption. There was a
clear distinction in patients and medical staff on the issue of adoption. The medical staff,
which included doctors, nurses, and doctors assistants, were more open to the idea of
adoption than the patients. This could be a reflection of the difference in their education and
understanding of infertility issues. A senior gynecologist was especially very supportive
about adoption; she conveyed If I were to rare a child to gratify my own maternal instincts, Ill
just pick up any child, maybe adopt somebody's child- ready made, why go through all that?
As a 30-year old doctors assistant revealed first, ...I wouldnt do it...I would adopt. Then on
further inquiring she said, someone from a poor family, whos suffering, I would adopt such a
child. Yet, another medical representative emphasized on the importance of education that
could possibly change peoples views on adoption, she argued, If someone is
educated...they are self-sufficient, they dont have to depend upon their families...they can
adopt... This idea goes back to the notion of extended families where the children are living
37


with the in-laws. Living with their in-laws, the son and the daughter-in-law were not free to
make their fertility decisions; that decision rested collectively on the extended family.
Patients, on the other hand, are reluctant to the notion of adoption. When asked
whether they were willing to adopt, it seemed that that was something patients were unwilling
to consider at that point in their lives. Most patients wanted to try the treatment first before
opting for other options such as adoption. There definitely was some stigma attached to the
concept of adoption. A 26-year-old medical staff thought that adoption is not an accepted
option; she expressed:
Its like that saying, Your bloods your very own...that adopted child is not
their very own! The idea of adoption in our society does not exist. I would say the
percentage who is supportive of it is zero...otherwise why should they sell their land,
their house and come all the way from the village to undergo IVF? They can adopt but
till now that trend for adoption hasnt come.
Another patient, a mother of two, on the topic of adoption conveyed:
We had thought about adopting at some point but then we thought against it
because people would have pointed fingers and would have labeled the child....I have
always wanted to adopt but listening to the horror stories of adopted children, I didnt
adopt; if it was solely my decision, I would have adopted 10 years ago! Due to the fact
that the environment is such, the child would never fit in and also I was worried about
my family not loving the child as much as they would love their own. Raising a child in
that environment would be a crime and because of that I didn't have the guts to adopt.
As a result of fear of the society and cultural constraints many women were reluctant
to adopt. As a 44-year-old mother of two put across I would use all my money for the
treatment. On asking, if she would adopt, her answer was no.
38


Outcome of IVF at OM Hospital
Due to the reason that people are so eager to undergo IVF treatment, the outcome of
IVF at OM hospital has been relatively successful. Being infertile is something that strongly
influences peoples lives in Nepal; having a child is imperative. Due to lack of available
treatment for infertility, patients traveled abroad to countries such as India, Thailand, or even
the United States for treatment. These individuals however were from upper to middle class
families. People from the lower class conversely could not afford to travel and had no
available options. Therefore introducing IVF was extremely necessary since 50 percent of
infertility exists among people who fall under the lower socioeconomic class, affirmed a 58-
year-old gynecologist. He further stated, It was very essential in this country because 15
percent of the population in spite of getting other treatment...are still infertile. The
importance of introducing this procedure was also stated by another gynecologist:
We have a section of patients who actually are able to afford the IVF
treatment, who were going abroad...to different parts of the world and then we came to
the conclusion that a lot of people can't afford it because its not only the cost of the
IVF, when you go abroad, you have to eat, you have to live somewhere, so thats a lot
of money that you are spending into an IVF. If the same facility were to be offered to
them locally it would cut a lot of cost and a lot of people may be able to avail of this
procedure.
Thus the outcome of IVF has been extremely successful since its introduction in
2004. This is reflected not only in the relatively high pregnancy rate but also from patients
support. IVF has given infertile couples hope, and as defined by a gynecologist is the last
resort treatment as patients try different treatments before seeking IVF. Although the
procedure does not offer a 100% success rate, patients are extremely satisfied with the
treatment they received. Almost all patients said that they were extremely satisfied with the
treatment, the medical staff and the services. A 29-year-old patient mentioned, It felt like
39
i


being a part of a family. Many patients liked the fact that they got to share their experience
and that the hospital provided that support system. A 42-year-old house wife expressed
...moral support is something that is very important, just treatment is not enough. I got a lot
of support from the staff at OM hospital...that type of support I would never have received if I
was elsewhere. About 78 percent of the medical staff indicated the importance of having
couple-centered treatment. In addition to the treatment, some doctors, explicitly,
acknowledged the importance of having strong faith or beliefs among themselves as well. A
male gynecologist who introduced IVF at OM described, We are adopting the latest
technology in IVF and that maybe the reason for our success rate...people have started
having faith that if they go to OM hospital, they will have 100 percent success...so theres a
rumor that if I touch the patient, theyll get pregnant!
Having strong faith in the doctors and the medical staff also shaped patients
experiences. It was through such beliefs that patients were willing to undergo treatment.
Due to the reason that patients had suffered family and societal pressure, being able to finally
conceive was not short of a marvel. As a gynecologist said, Its a blessing, they think this is
it! These doctors, these nurses, this whole team are like God sent to them...it's like a miracle
come true. Also, a nurse described what patients express when they have a successful
outcome: They say, Were so happy. You are God...we never thought we would have
children but now we do! The patients also bring presents to thank us. So they think that
doctors are God themselves...they are extremely overjoyed.
Although the IVF center at OM hospital is in its initial stages, it has made significant
changes to people lives. It has given infertile women a chance to have children, which was
not a possible option just a few years back. As a result of egg-sharing and use of donor in
40


IVF, it has changed the concept of family and has made people more accepting of the options
available to them. People have also been trying to educate themselves about this technology
and are more aware of the treatment itself. Since its introduction, it has changed peoples
psychologies by either reinforcing ones faith in God or has made them more supportive of
the treatment itself. In a society where womens status is defined by their motherhood, it has
given women hope and a chance to possibly fulfill their dreams. In a culture that is so
traditional in its views, IVF has redefined family relationships and social life. Despite the fact
that the concept of IVF is still not fully accepted and many are forced to keep the treatment a
secret, it has opened doors to new possibilities for infertile women.
41


CHAPTER 5
CONCLUSION
This study supports the social construction perspective that people constantly
redefine their lives through social interactions. In the case of IVF, people were defining what
it meant to be infertile through their interactions, and by evaluating the available options. This
was true both for patients and the medical team, for both parties had to reconstruct their IVF
experience through the shared reality of everyday living (Wallace and Wolf, 2006). Menning
discussed that humans do not posses instincts that make them want to have children but
rather it is the intricately learned roles and expectations from society, that make them act the
way they do (1977, p.93). The same has been observed through the interviews. While for
patients, it was especially the family that defined the importance of having a child; for doctors,
their management was based on handling the cultural as well as the medical aspects of
treatment. A womans status was defined through what was the societal norm, which in this
case, was having a child. Through the cultural system then, the meaning and values of
childlessness were built (Chhetri and Gurung, 1999). Peoples experiences of IVF thus, were
results of social factors (Matthews and Matthews 1989b) specifically as defined by the family,
the culture, and the society.
Another most apparent issue involving IVF was peoples strong faith in God. Since
majority of the population in Nepal are Hindus, having a strong faith in God is inculcated in
the people from early on. With such a belief system in place, faith gave individuals the hope
and strength while seeking treatment. Even when the outcome was unsuccessful, they had
their faith to fall upon, as a way to seek answers outside their realm of control (Menning,
42


1977). Husbands support was also undoubtedly an important aspect of seeking IVF. All
respondents emphasized on the importance of having that support system. The main
difficulty patients faced was costs related to treatment, which also affected the use of IVF at
OM hospital. Financial burden appeared to weigh most on patients, some could only afford
to undergo treatment once and, therefore, it was a major undertaking on their part.
Even though a loss of sense of control was identified by numerous researches
(Abbey et al., 1992; Callan, 1987; Matthews and Matthews, 1986b; Porter and Christopher,
1973), patients mostly did not express feeling as such. This could be because the patients
either had already experienced the initial shock of being infertile or, had built a strong support
system. The fact that most patients were in their 40s also changed the dynamics of ones
experience. They might have reached the resolution stage as defined by Mennings (1980),
since they had been infertile for so long. A lot of the patients had decided to undergo
treatment once and for all. This was their last attempt at doing something about their
infertility. Also contrary to Modells (1989) research, that parents were more willing to adopt
than using donor or surrogacy, if IVF failed; the patients in this study were more accepting of
egg-sharing. This could be a result of the cultural emphasis on children. Also, since the
doctors particularly emphasized on the bonding that took place between the parent and child,
patients were more accepting of IVF through the use of donors than adoption.
Understanding IVF introduction can only be comprehended through peoples
interpretation, and required the data to be gathered through a qualitative study. Since the
sample was drawn from non-probability sampling method and the sample size being small,
the findings cannot be generalized to the larger population. This was one of the central
weaknesses of the study. It is particularly important to note that males in the sample were
43


underrepresented. This underrpresentation may be due to the less participation of males, as
a result of the cultural factors, where men are not comfortable discussing personal issues and
could explain their unwillingness to participate in the research. Another weakness is the fact
that the respondents were asked to rely on their memory of their IVF experience before,
during, or after treatment, which may not be accurate. There definitely will be restrictions to
how much and what information one can remember. Furthermore, IVF is a relatively
sensitive issue, making respondents less willing to talk, again limiting the data. Additionally,
there were cultural practices that discouraged women to speak up. The women were
extremely shy and nervous to talk. Therefore, the validity and generalizability of the results
are limited and much caution must be taken in interpreting the results.
One of the main strengths of this study is the fact that no study has yet explored the
issue of IVF in Nepal and studied it holistically. Research in Nepal has added cultural
characteristics and components that are unique to Nepalese culture, through which future
researchers can draw from. This study is also unique because IVF has just started in Nepal
in 2004, and, therefore, has paved way for further research at OM hospital. Since the study
was done through in-depth interviews, peoples true experiences were identified. There are
also some of the practical implications of the study. The experience of undergoing IVF is
different in different situations because it is culturally and socially defined. It thus is
imperative for medical professionals and researchers alike to keep in mind peoples
experiences and backgrounds. In addition, physicians need to be articulate in expressing
their views since it shapes the patients interpretation of infertility and treatment (Greil et al.,
1988); they should be clear in order to avoid misinterpretation or confusion among patients.
The study also indicated the importance of having routine counseling in regards to treatment
i
44


and societal issues, since patients had a hard time fully grasping the concept of IVF
especially if they are uneducated, or are from a lower socioeconomic class.
In order to fully understand and generalize the issues pertaining IVF, a fully ranged
study on this subject is required. Future research design should focus on sampling a larger
population overtime, which would allow the researchers to study the continual progress and
changes that IVF has brought forth in the Nepalese community. Further research should also
focus on the outcome of the children who are born as a result of IVF, to analyze their
development and treatment in the family as they become adolescents. Future research may
possibly include measuring the increase or decrease in peoples knowledge and acceptance
of IVF, as the use of this technology expands in Nepal.
45


APPENDIX A
CHARACTERISTICS OF DOCTORS IN SAMPLE (IN PERCENTAGES)
Average Age 35.56
Sex
Male 11.11%
Female 88.89%
Educational Level
Less than High School 0.00%
High School 22.22%
Bachelors 22.22%
Masters 44.44%
PhD 0.00%
Other 11.11%
Employment Status
Full Time 88.89%
Part Time 11.11%
No Employment/other 0.00%
Retired 0.00%
Average Monthly Income (In rupees)
Less than 10,000 55.56%
10,000 20,000 0.00%
20,000 30,000 0.00%
30,000 40,000 0.00%
40,000 50,000 11.11%
50,000 or More 33.33%
No Income 0.00%
Marital Status
Single 22.22%
Married 66.67%
Divorced 0.00%
Widowed 11.11%
Religious Affiliation
Hindu 88.89%
Non-Hindu 11.11%
Do you have any children
Yes 77.78%
No 22.22%
46


APPENDIX A (Cont.)
CHARACTERISTICS OF DOCTORS IN SAMPLE (IN PERCENTAGES)
Rating of IVF at OM Hospital
Very Successful 66.67%
Fairly Successful 33.33%
Somewhat Successful 0.00%
Not as Successful 0.00%
Not Successful at all 0.00%


APPENDIX B
CHARACTERISTICS OF PATIENTS IN SAMPLE (IN PERCENTAGES)
Average Age
Sex
Male
Female
Educational Level
Less than High School
High School
Bachelors
Masters
PhD
Other
Employment Status
Full Time
Part Time
No Employment/other
Retired
Average Monthly Household Income (Rupees)
Less than 10,000
10,000-20,000
20.000 - 30,000
30.000 - 40,000
40.000 - 50,000
50.000 or More
No Income
Marital Status
Single
Married
Divorced
Widowed
38.31
15.38%
84.62%
23.08%
15.38%
46.15%
7.69%
0.00%
7.69%
30.77%
0.00%
69.23%
0.00%
0.00%
23.08%
7.69%
0.00%
7.69%
46.15%
15.38%
0.00%
100.00%
0.00%
0.00%
48


APPENDIX B (Cont.)
CHARACTERISTICS OF PATIENTS IN SAMPLE (IN PERCENTAGES)
If Married, How Many Years
Less than 1 year
2 years
3 years
4 years
5 years
More than 5 years
Average years of marriage over 5 years
Average age of marriage
Religious Affiliation
Hindu
Non-Hindu
Individuals with at least one child
Individuals with no children
Number of years attempting to get pregnant
Less than a year
2 years
3 years
4 years
5 years
More than 5 years
Diagnosed Infertility Problem
Wife
Husband
Both
Unaware
0.00%
0.00%
0.00%
0.00%
7.69%
92.31%
17.46
21.77
100.00%
0.00%
30.77%
69.23%
15.38%
0.00%
0.00%
15.38%
0.00%
69.23%
46.15%
15.38%
7.69%
30.77%
49


APPENDIX B (Cont.)
CHARACTERISTICS OF PATIENTS IN SAMPLE (IN PERCENTAGES)
Length of time undergoing IVF Treatment
Less than a year 61.54%
2 years 15.38%
3 years 0.00%
4 years 7.69%
5 years 0.00%
More than 5 years 15.38%
Average number of IVF treatments undertaken 2.15


APPENDIX C
NUMBER OF BATCHES AND OUTCOME OF IVF
Batches Total Patients Total Pregnancies (live births) Total Clinical Pregnancies (conception- not live births) Percentage of Total Pregnancies Percentage of Total Clinical Pregnancies
1 17 7 3 41% 18%
2 19 9 6 47% 32%
3 17 5 4 29% 24%
4 22 8 7 36% 32%
5 24 6 6 25% 25%
6 20 6 4 30% 20%
7 31 10 8 32% 26%
8 28 14 12 50% 43%
9 15 5 4 33% 27%
10 22 7 4 32% 18%
11 21 11 9 52% 43%
12 17 5 4 29% 24%
13 22 8 5 36% 23%
14 28 13 10 46% 36%
Total 303 114 86 38% (Mean) 28% (Mean)
50


APPENDIX D
CONSENT FORM
The introduction of IVF treatment in Nepal has opened doors for the advancement and use of
new technology as it pertains to human reproduction. Since this treatment is fairly new, we
are unaware of its effects on the local Nepalese population. I am respectfully asking you to
take part in a study that explores issues-positive and negative that IVF has set in motion.
Your participation shall be invaluable for analyzing the impact of IVF introduction in Nepal.
This research is in partial fulfillment of my Maters of Arts in sociology through the University
of Colorado at Denver/Health Science Center. For the purpose of obtaining data, a series of
open-ended questions will be asked that will encompass discussing your feelings, general
questions and concerns you may have about IVF and your feelings on infertility. The duration
of the interview should be approximately forty-five minutes to an hour. The results from this
study would help discover how the population of Kathmandu has received the introduction of
IVF. Additionally, your participation will also contribute to science by adding knowledge in the
filed of sociology in Nepal.
Participation in this study is completely voluntary and you may at any time withdraw from the
study. The interview will be audio-taped and if asked, I shall turn off the tape at any point of
the interview. All the information provided shall remain confidential at all possible costs. All
the tapes and questionnaire shall be stored at the Department of Sociology at the University
of Colorado at Denver/Health Science Center.
I sincerely appreciate you participation. If you have any questions before, during or after the
study, you can email me at hifmuchu @ hotmail.com or my faculty advisor, Dr. Candan Duran-
Aydintug at the Department of Sociology, University of Colorado at Denver/Health Science
Center, P.O. Box 173364 Denver, Colorado 80217 (303) 556-3510. Questions concerning
your rights as a subject may be directed to the Office of Academic Affairs, CU Denver
Building Suite 700, (303) 556-2550.
Thank you for your time.
Sincerely,
Supriya Koirala
Primary Researcher
/________________________________________ understand the above information and give my
consent in participating in the research conducted by Ms Supriya Koirala at the OM Hospital
Research Center. I also understand that my participation is completely voluntary and that all
information shall be kept strictly confidential.
51


APPENDIX D (Cont.)
Print Name
Date
52


APPENDIX E
Questionnaire- Patients
1. Age..............
2. Sex
o Male
o Female
3. What is your
educational level?
o Less than high school
o High School
o Bachelors
o Masters
o PhD
o Other (Please Specify)
4. What is your
employment status?
o Full time
o Part time
o No Employment
o Retired
o Other (Please
Specify)
5. Whether employed or
not, what is your title?
Either job related
such as manager,
teacher, engineer or
other as such
housewife, stay home
father etc. (Please
Specify)
6. What is your average
monthly household
income in rupees?
o Less than
10,000
o 10,000-20,000
o 20,000-30,000
o 30,000-40,000
o 40,000-50,000
o 50,000 or more
o No Income
7. What is your marital
status?
o Single
o Married
o Divorced
o Widowed
8. If married, how many
years have you been
married?
O Less than 1 year
o 2 years
o 3 years
o 4 years
o 5 years
o More than 5
years
If you are married for
more than 5 years,
please specify how
many years in the
space provided below
9. What is your religious
affiliation?
o Hindu
o Christian
o Muslim
o Other
o None
10. Do you have any
children (live
birth/adopted)? (Yes /
No)
If Yes, please specify
number:
11. How many years
have you been
attempting to get
pregnant?
o Less than 1 year
o 2 years
o 3 years
o 4 years
o 5 years
o More than 5
years. Please
Specify number
of years
12. Who in the
relationship has been
diagnosed with
infertility problem?
o You
o Your partner
o Both
o Dont know
13. How accepting have
your family members
(from your partners
side of the family)
been with regards to
your infertility?
o Extremely
accepting
53


APPENDIX E (Cont.)
o Very Accepting
o Somewhat
accepting
o A little accepting
o Not at all
accepting
o Dont know/ No
response
14. How accepting have
your family members
(from your own side
of the family) been
with regards to your
infertility?
O Extremely
accepting
o Very Accepting
o Somewhat
accepting
o A little accepting
o Not at all
accepting
o Dont know/ No
response
15. How supportive are
your family members
(from your partners
side of the family) for
fertility treatment?
o Extremely supportive
o Very supportive
o Somewhat supportive
o A supportive little
o Not at supportive all
o Dont know/ response No
How supportive are
your family members
(from your own side
of the family) for
fertility treatment?
o Extremely
supportive
o Very supportive
o Somewhat
supportive
o A little
supportive
o Not at all
supportive
o Dont know/ No
response
17. How supportive have
your friends been for
fertility treatment?
o Extremely
supportive
o Very supportive
o Somewhat
supportive
o A little
supportive
o Not at all
supportive
o Dont know/ No
response
18. What is the length of
time you or your
partner or together,
have been
undergoing IVF
treatment?
o Less than 1 year
o 2 years
o 3 years
o 4 years
o 5 years
o More than 5
years. (Please
Specify how
many years)
19. How many IVF
treatments have you
or your partner
undergone? (Please
specify in numbers)
20. Who was responsible
for taking the initiative
for undergoing IVF
treatment?
o You
o Your partner
o Other family
member
o Your doctor
Other (Please
Specify)
21. How often do you
think about your
infertility problem in a
day?
o Constantly
o More than 10
times a day
o 5-10 times a day
o Less than 5
times a day
o Not at all
22. What aspect of your
life has your infertility
most impacted?
Choose as many as
applicable.
O Your self (your
confidence, self-
esteem etc)
o Marriage
o Family life
o Social
relationship
o Commitment to
career
54


APPENDIX E (Cont)
Other
(Please Specify)
23. How would you rate
your relationship (in
terms of
communicating with
your partner) after
having undergone
IVF treatment?
o Excellent
o Good
o Average
o Below average
o Poor
o Dont know
24. Please rank in order
of importance of
support you get from
each group. Arrange
in numbers 1-3, 1
being most
supportive.
....Family support
....Social support
....Spiritual support
....Other (If you
have other support as
well, do not rank but,
please specify in the
space provided
below).
25. Please indicate some
other alternatives
medical or not, you
would be willing to try
to get pregnant?
o More medical
treatment (such
as embryo
transfer, sperm
donation
including IVF)
o Surrogacy
o Adoption
o Other (Please
Specify)
26. How satisfied are you
with medical
treatment that you
have received so far
at OM Hospital?
o Completely
satisfied
o Mostly satisfied
o Somewhat
satisfied
o Neither satisfied
nor dissatisfied
o Mostly
dissatisfied
o Completely
dissatisfied
27. How would you rate
your satisfaction level
with your current
medical doctor at OM
Hospital?
o Completely
satisfied
o Mostly satisfied
o Somewhat
satisfied
o Neither satisfied
nor dissatisfied
o Mostly
dissatisfied
o Completely
dissatisfied
28. How would you rate
the overall emotional
support given by
medical staff at OM
hospital?
o Very supportive
o Fairly supportive
o Somewhat
supportive
o Less supportive
o Not supportive
at all
End of Questionnaire- Patients
55


APPENDIX F
Questionnaire Medical
Professionals
(Administrators, doctors,
nurses, and other staff)
1. Age..............
2. Sex
o Male
o Female
3. What is your
educational level?
o Less than high
school
o High School
o Bachelors
o Masters
o PhD
o Other (If medical
doctor or any
other degree,
please specify
on other in the
space provided
below)
4. What is your job title?
Such as gynecologist,
nurse, medical
assistant, medical
student etc (Please
Specify)
5. What is your
employment status?
o Full time
o Part time
o No Employment
o Retired
o Other
6. What is your average
monthly income
household income in
rupees?
o Less than
10,000
o 10,000-20,000
o 20,000-30,000
o 30,000-40,000
o 40,000-50,000
o 50,000 or more
o Not applicable
7. What is your marital
status?
o Single
o Married
o Divorced
o Widowed
8. If married, how many
years have you been
married?
o Less than 1 year
o 1 year
o 2 years
o 3 years
o 4 years
o 5 years
o More than 5
years
If you are married for
more than 5 years,
please specify how
many years in the
space provided below
9. What is your religious
affiliation?
o Hindu
o Christian
o Muslim
0 Other
o None
10. Do you have any
children (live
birth/adopted)?
(Please Specify)
11. How would you rate
the outcome of IVF
since its introduction
at OM Hospital?
o Very successful
o Fairly successful
o Somewhat
successful
o Not as
successful
o Not successful
at all
12. Since the introduction
of IVF in the hospital,
how has your
workload changed?
o Very
significantly
o Fairly
significantly
o Somewhat
significantly
o Not as
significant
o Not significant at
all
o Not applicable
13. How supportive are
you personally of IVF
treatment?
56


APPENDIX F (Cont.)
o Very supportive
o Fairly supportive
o Somewhat
supportive
o Less supportive
o Not supportive
at all
14. Based on the current
success rate, how
beneficial do you
think this procedure is
on infertile patients?
o Very beneficial
o Fairly beneficial
o Somewhat
beneficial
o Less beneficial
o Not beneficial at
all
15. Is the treatment or
support you provide
for patients primarily-
o Couple-oriented
o Individual-
oriented
Other (Please
specify)
16. How important is
management of
feelings in treating
patients undergoing
IVF?
o Very important
o Fairly important
o Somewhat
important
o Less important
o Not important at
all
17. Please list in order (1
through 6) from most
common to least
common (1=most
common, 6=least
common) the
reactions youve
noticed from patients
on knowing they have
infertility problems?
.....Surprise
.....Denial
.....Anger
.....Isolation
.....Guilt
Grief
18. What would you say
is the number one
support for patients
undergoing IVF,
based on your
experience?
o Self (having
strong self-
esteem,
confidence etc)
o Family
o Physicians
Other (Please
specify)
End Questionnaire Medical
Professionals
(Administrators, doctors,
nurses, and other staff)
57


APPENDIX G
IVF IN NEPAL INTERVIEW GUIDELINE
Interviewer:
Date:
Time Began:
Time End:
Interview Location:
Administrators:
Key points
Why introduce IVF
Financial benefits
Prestige- for hospital, doctors
What changes or difference are they making in peoples lives
Plans for the future
Sample Questions
What were the reasons for the introduction of IVF (Helping people, increase
revenue, technological advancement)?
As a result of some of the successes, what has been peoples reaction? Are they
supportive or skeptical, any other responses? How has the outcome been? News,
Publicity-how people have received the outcome.
What do think is the most important change that introduction of this technology
has brought to the society in general (changes in terms of peoples
thinking/perception/acceptance of use of IVF)?
What are the obstacles they faced? How has the support been?
Doctors:
Key points
Outcome of IVF-successes and failures
Patients feelings on this issue (their moral standing, issues about egg sharing?)
Struggles they have seen patients involved in
Their personal take on IVF (whether they support it, for how long will they
encourage treatment)
Effect on their practice
Sample Questions
Approximately what would you say is the success rate of IVF here compared to
what you know about the worlds average (in percentages)
What infertility problems do patients mostly have?
58


APPENDIX G (Cont.)
IVF IN NEPAL INTERVIEW GUIDELINE
Undergoing IVF treatment surely must be stressful for your patients, how do you
make your patients feel less stressed?
How do you deal with the pressure of having to produce desired outcome every
time you perform an IVF treatment?
Patients:
Key Points
How long they have been infertile and how long they have undergone treatment
How did they find out about IVF- how did it start?
Whose decision it was to undergo treatment
Their views about infertility
Their feelings about IVF (moral stand, egg-sharing/use of donor)
Coping strategies
Their marriage prior to and after undergoing or having undergone treatment
Other alternative like adoption
Your suggestions to make it better
Sample Questions
What does infertility mean to you?
Living in a society where fertility is considered to be under ones control, the
realization of having infertility problems may have come as a surprise and shock
to you. How did you feel?
Did you experience /sense a loss of control?
How does having a child change your life? Or how important is it to have a child of
your own?
Im sure there were a lot of times you have wanted to give up treatment, what
would you say are the main factors that has kept you continuing treatment (your
significant other, family pressure, own beliefs)?
How long do you think you will keep up with treatment?
Have you been stigmatized in any way by your family, peers, neighbors? Do they
blame you for the infertility?
How has your relationship changed with your partner (more conflict, better
understanding)?
How openly can you confide in your partner?
Other Medical Staff
Key Points
Their personal stand of IVF
The services they provide
Things they see lacking or are exceptionally good
Changes they have seen in the hospital and also in peoples lives
59


APPENDIX G (Cont.)
IVF IN NEPAL INTERVIEW GUIDELINE
Sample Questions
Since the introduction of IVF, what changes have you seen in the a.
administration, b. doctors, c. patients
Do you think this procedure puts a lot of pressure on the medical team to obtain
the desired outcome?
How do you handle stress with a. patients, b. yourself?
What changes have you seen in patients (stress, change in attitude, behavior,
and family pressure)?
60


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