D. Litt. et Phil. / Psychogenic infertility is both a medically and psychologically complex issue for women who have tried for several years to have a baby. Irrespective of etiology, infertility may be a very intense and stressful experience for both partners, affecting their relationship, sexuality, self-esteem, body image and identity. The ‘not knowing’ of psychogenic infertility creates uncertainty and anxiety, and may represent a crisis for many women. Conceiving and raising a child has social and cultural meaning that may precipitate a sense of loss about her female identity if she is not able to have a baby. The study’s exploration of psychogenic infertility entails four aspects: - an investigation of both the overt and covert attitudes of psychogenically infertile women towards dimensions of the feminine role, and an assessment of this quantitative analysis to determine which of the feminine role factors are significant - an analysis of the twenty-one case studies to investigate the life scripts of each woman and how these relate to: her femininity and her acceptance of her feminine role; her sense of motherhood and her motherliness; her own mother-daughter relationship; and to her psychogenic infertility. - a narrative exploration with one woman which incorporates these significant factors together with elements of her life scripts, using an integrated scripts, psychodynamic and narrative approach for the analysis - a storied account of the narrative exploration with one psychogenically infertile woman, in an effort to explore the relationship between femininity and life scripts in the psychogenesis of unexplained female infertility, and to investigate the possible therapeutic value of a therapeutic intervention for women experiencing unexplained infertility, specifically an intervention that would integrate: exploration of life scripts, psychodynamic understanding and narrative re-storying of her infertility. Therapeutic intervention for women experiencing infertility is often focused on the stress experienced and on cognitive-behavioural ways of living with the distress. Literature to date does not indicate a therapeutic framework based on an approach that integrates elements of life scripts, psychodynamic, and narrative therapies to explore how scripts about femininity and motherhood may be unknowingly preventing the women from identifying with her female role of conceiving a baby.

Bakgrund: Infertilitet är ett sjukdomstillstånd som innebär att ett par inte kan uppnå en klinisk graviditet under mer än ett år av försök. Det är mellan 10-15 % av alla par i fertil ålder som drabbas av tillståndet i varje land. Orsaken som hittas i 90 procent av fallen är antingen manliga, kvinnliga eller gemensamma faktorer. När ingen orsak hittas kallas det för oförklarlig-, eller idiopatisk infertilitet. Innan diagnostisering och eventuell behandling utförs därför noga utredningar med analyser på både kvinnan och mannen. Behandlingen bestäms därefter utifrån orsak. Vid kvinnlig infertilitet är in vitro-fertilisering (IVF) den mest vanliga icke-farmakologiska proceduren som används framför allt vid oförklarlig infertilitet och åldersfaktorer. Antiöstrogenet klomifencitrat har i många decennier varit farmakologiska förstahandsbehandlingen vid anovulatorisk infertilitet men vid de senaste 10 åren har den ersätts med aromatashämmaren letrozol som med en liknande mekanism kunnat ge upphov till ovulationsstimulering. Syfte: Syftet med examensarbetet var att utvärdera och jämföra effekterna av antiöstrogenet klomifencitrat med aromatashämmaren letrozol vid infertilitetsbehandling hos kvinnor. Metod: För att uppnå syftet utfördes litteratursökningar av relaterade vetenskapliga studier i den medicinska databasen PubMed. Nyckelorden som användes vid sökning var “female infertility”, “clomiphene” och “letrozole” och därefter hämtades fem randomiserade kontrollerade vetenskapliga artiklar (RCT) som granskades i resultatdelen av arbetet. Resultat: Samtliga studier, utom studie 5, visade att aromatashämmaren letrozol hade bättre effekt på ovulationstimuleringen och därmed också att uppnå klinisk graviditet än vad klomifencitrat hade. Administrering av letrozol ledde också till större tjocklek av endometrium och fler antalet mogna folliklar. Å andra sidan visade sig letrozol ge högre sannolikhet till multipla graviditet i studie 5. Det förekom ett par fall av allvarliga biverkningar under administrering av samtliga läkemedel, dock var majoriteten av biverkningarna milda och förekom i form utav huvudvärk, illamående, gastrointestinala besvär, trötthet och värmevallningar. Slutsats: Resultaten tyder på att letrozol är ett mer effektivt alternativ till infertilitetsbehandling av kvinnor. Eftersom den dessutom har mycket lägre halveringstid än klomifencitrat gör den mer säker att använda då det låg östrogennivå är ej optimal hos kvinnor i fertil ålder. / Background: Infertility is a condition that is based on a couple not being able to achieve a clinical pregnancy for more than a year of trying. Between 10-15 % of all heterosexual couples of childbearing age are affected by the condition in each country. The cause that is found in 90 percent of cases is either male-, female- or common factors. When no cause is found, it is called unexplained or idiopathic infertility. Before diagnosis and possible treatment, careful investigations are therefore performed with analysis on both the woman and the man. The treatment is then determined based on the cause. In female infertility, in vitro fertilization (IVF) is the most common non-pharmacological procedure used primarily for unexplained infertility and age factors. The antiestrogen clomiphene citrate has for many decades been the first-line parmacological treatment for anovulatory infertility, but in the last 10 years it has been replaced by the aromatase inhibitor letrozole, which with a similar mechanism have effect on ovulation stimulation. Aim: The aim of this thesis was to evaluate and compare the treatment effects of the antiestrogen clomiphene citrate with the aromatase inhibitor letrozole in female infertility. Method: A literature search of related scientific studies was implemented in the medical database PubMed. The keywords used in the searchfield were ”female infertility”, ”clomiphene” and ”letrozole” and then five randomized controlled trial articles (RCT) were selected to be reviewed in the results part of the thesis. Results: All studies, except for study 5, showed that the aromatase inhibitor letrozole had a better effect than clomiphene citrate on ovulation stimulation and thus also to achieve a clinical pregnancy. Administration of letrozole also led to greater endometrial thickness and increased numer of mature follicles. In study 5 on the other hand, letrozole was shown to increase the likelihood of multiple pregnancies. There were a couple of cases of serious side effects during the administration of these drugs, however, the majority of the side effects were mild and occured in the form of headaches, nausea, gastrointestinal disorders, fattigue, and hot flashes. Conclusion: In conclusion, the results suggest that letrozole is a more effective alternative to infertility treatment for women. In addition, since it has a much lower half-life than clomiphene citrate, it is safer to use as low estrogen levels are not optimal in women of childbearing potential.

Abstrakt (svenska) Titel: Infertilitet – vems rätt att bestämma? En kvalitativ intervjustudie kring barnmorskors erfarenheter av att arbeta med infertilitet. Författare: Rebecka Kristensen Berlin, Umeå Universitet -Institutionen för Omvårdnad   Syfte: Att undersöka hur barnmorskans erfarenheter av parens reaktioner uppfattas i samband med infertilitetsproblematik. Studiedesign: En kvalitativ intervjustudie innefattande fyra barnmorskor har genomförts på en barnmorskemottagning. Intervjumaterialet analyserades utifrån kvalitativ innehållsanalys, vilket i korthet innebar följande steg: Materialet transkriberades ordagrant och bröts därefter ned i meningsbärande enheter, för att kunna sortera data utifrån innehåll. Kondensering utfördes i syfte att lyfta fram kärninnehållet. Abstraktion utfördes för att få fram koder, i syfte att reducera mängden text men även för att därefter kunna sammanfoga snarlika ämnen till underkategorier, vilka sedan grupperades i huvudkategorier tillhörande ett gemensamt tema. Resultat: De fyra huvudkategorier som uppkom var känslor, kommunikation, rättighet och prevention. Känslor: Oro, stress samt nedstämdhet var vanligt förekommande. Mäns känslor var svårare att identifiera då kvinnor ibland kom ensamma till besöken, samt män ibland dolde känslor bakom aggressivitet. Kommunikation: God information skapade förtroende. Råd om livsstilsförändringar samt vidareremittering var en viktig form av stöd. Rättighet: Ingen har rätt till barn, men alla ansågs ha rätt att försöka få barn. Privatekonomi samt samhällets krav påverkar dock i stor utsträckning paren vid misslyckade försök eller önskan om ytterligare barn. Prevention: Vikten av information kring infertilitet vid undervisning i skolan, vid preventivmedelsamtal och vid cellprovtagning poängterades. Slutsats: Att vara väl införstådd med de känslor som kan uppstå i samband med infertilitet möjliggör att ge tillfredställande stöd. Särskilda ansträngningar behöver göras för att nå män, såväl emotionellt som preventivt. Stort utrymme för förbättring finns gällande preventiva åtgärder, i syfte att fördjupa allmänhetens kunskaper kring infertilitet. Nyckelord: kvinnlig infertilitet; manlig infertilitet; känslor; barnmorska; kvalitativ forskning / Abstract (English)     Title: Infertility. Who´s right to decide? A qualitative interview study regarding midwives experiences to work with infertility. Author: Rebecka Kristensen Berlin, Umeå University- Department of nursing   Objective: To investigate midwives thoughts and experiences regarding couples reactions in connection with infertility.  Study design: A qualitative interview study comprising four midwives have been conducted. The resulting data was analyzed using qualitative content analysis, consisting of the following steps: The material was transcribed verbatim and then broken down into sentences, to aid in sorting the data based on content. Condensation was carried out in order to highlight the core content. Abstraction was performed to obtain codes, in order to reduce the amount of text , but also to subsequently merge similar content into subcategories , which were then grouped into categories. Results: Four main categories emerged. Feelings: anxiety, stress and depression were common. Men’s feelings were more difficult to identify since women sometimes came alone to appointments, and men sometimes concealed their feelings behind aggression. Communication: Good information created trust. Advice on lifestyle changes and referrals were important forms of support. Empowerment: No-one has the right to a child, but the right to try to have a child. Personal and societal demands, however, affect the couples at failure to conceive or desire for additional children. Prevention: The importance of information about fertility in school, at contraception counselling and routine smear exams was emphasized. Conclusion: Awareness of the feelings that infertility may give rise to, enables providing satisfactory support. Further efforts need to be made to reach males emotionally as well as preventatively. There is great possibility for improvement in regards to public awareness about infertility. Keywords: female infertility; male infertility; emotions; midwife; qualitative research

L'Organisation Mondiale de la Santé définit l'infertilité comme une maladie et un échec de l'appareil reproducteur à parvenir à une grossesse après 12 mois ou plus de rapports sexuels réguliers non protégés. De nos jours, l'infertilité est devenue un phénomène commun affectant 1 couple en âge de procréer sur 5. Une origine idiopathique est le plus souvent associée à un système immunitaire actif qui pourrait produire des niveaux élevés d'anticorps anti-liquide séminal ou anti-sperme. L'auto-immunisation, aussi bien que l'iso-immunisation, joue un rôle significatif dans jusqu'à 30% des cas signalés. Le liquide séminal, qui est défini comme un fluide complexe contenant le sperme, les vésicules cellulaires et autres cellules et composantes, pourraient immuniser l'appareil génital féminin. Cette thèse est liée à l'infertilité féminine immune, en particulier à l'iso-immunisation féminine. Une meilleure compréhension de cette manifestation physiopathologique consiste en (1) la détermination des isotypes d'anticorps jouant un rôle significatif dans cette maladie, puis en (2) la caractérisation et l'identification des antigènes de liquide séminal ou de sperme reconnus par ces anticorps, (3) la proposition de marqueurs diagnostiques potentiels afin d'adapter des thérapies spécifiques, et, en outre, la conception d'un outil de diagnostic miniaturisé basé sur les marqueurs sélectionnés, (4) la suggestion d'une éventuelle immuno-intervention. En se fondant sur la distribution des isotypes d'anticorps spécifiques au liquide séminal/sperme, nous suggérons que les immunoglobulines E, M, A1,2, et G3 ne sont pas impliquées dans la sensibilisation physiopathologique chez les femmes. Les IgG4, semblent constituer la sous classe majeure interagissant avec les protéines de sperme. A l’inverse, les IgG1 semblent être principalement impliquées dans la réactivité vis-à-vis des protéines séminales. Nous avons également élargi le groupe déjà existant d’IgGs liés aux protéines de sperme à d’autres protéines, parmi lesquelles la protéine de choc thermique 70 1A/1B, la protéine apparentée aux protéines de choc thermique 71kDa et l’alpha-énolase ont été reconnues, pour la première fois, être liés à l’iso-immunisation féminine. Nous avons mis en évidence le rôle des protéines séminales dans l’iso-immunisation et pas seulement dans l’hypersensibilité au sperme par l’intermédiaire d’IgE. En particulier, l’antigène spécifique de la prostate, la phosphatase acide prostatique et la protéine à doigt de zinc 778 ont été décrites comme immuno-dominants parmi les protéines séminales reconnues par des IgGs liés aux protéines de sperme. La détermination des sous classes d’IgG de sérum féminin, spécifiques au liquide séminal/sperme, pourrait rendre le diagnostic des patients plus complet. Les IgG1 et IgG4 anti-liquide séminal/sperme pourraient présenter un intérêt pour l’immunothérapie. Par ailleurs, les protéines décrites, dans notre étude, pourraient se révéler être des bio marqueurs utiles pour de telles pathologies. Le dispositif miniaturisé pourrait être de type LFIA (Lateral Flow Immuno Assay), se basant sur la détection immuno-chimique d’anticorps spécifiques. L’immuno-intervention envisagée pourrait reposer sur l’effet d’immunoglobulines intraveineuses. / The World health Organization reports infertility as a disease and a failure of reproductive tract to achieve pregnancy after 12 months or more of regular unprotected sexual intercourse. Nowadays, infertility has become a common life phenomenon affecting 1 out of 5 couples at reproductive age. Idiopathic cause is mostly associated with active immune system which may produce high levels of anti-seminal and/or anti-sperm antibodies. Auto-immunization as well as iso-immunization has a significant role in up to 30% of reported cases of infertility. Semen that is defined as a complex fluid containing sperm, cellular vesicles and other cells and components, could immunize the female genital tract. This thesis is related to female immune infertility, in particular to female iso-immunization. The better understanding of this pathophysiological event consists of (1) the determination of antibody isotype playing a significant role in this disease, then (2) the characterization and identification of semen antibody-binding proteins, seminal and/or sperm, (3) the proposal of potential diagnostic markers to adapt specific therapy and, in addition, the design of miniaturized diagnostic tool based on the selected markers, (4) the suggestion of potential immuno-intervention. Based on the distribution of seminal/sperm-specific antibody isotypes, we suggest that immunoglobulins E, M, A1,2, G3 are not involved in the primary pathophysiological female sensitization. IgG4 appears to be the major subclass interacting with sperm proteins. On a contrary, IgG1 seems to be the one mainly involved in the reactivity towards seminal proteins. We have also extended the existing group of IgG-binding sperm proteins, among which heat shock protein 70 1A/1B, heat shock cognate protein 71 kDa and alpha-enolase have been shown, for the first time, to be related to female iso-immunization. We have put the emphasis on the role of seminal proteins in iso-immunization and not only in the IgE-mediated semen hypersensitivity as known so far. In particular, prostate-specific antigen, prostatic acid phosphatase and zinc finger protein 778 have been determined as immunodominant among IgG-binding seminal proteins. The determination of female serum seminal/sperm-specific IgG subclasses could make the patient diagnoses more comprehensive. Anti-seminal/sperm IgG1,4 might be of interest for immunotherapy. Furthermore, the herein described proteins could be useful biomarkers of such pathology. The miniaturized chip could be a lateral flow immunoassay-based device acting on the immunochemical detection of specific antibodies. The intended immuno-intervention could consist of the effect of intravenous immunoglobulins.

The World health Organization reports infertility as a disease and a failure of reproductive tract to achieve pregnancy after 12 months or more of regular unprotected sexual intercourse. Nowadays, infertility has become a common life phenomenon affecting 1 out of 5 couples at reproductive age. Idiopathic cause is mostly associated with active immune system which may produce high levels of anti-seminal and/or anti-sperm antibodies. Auto-immunization as well as iso-immunization has a significant role in up to 30% of reported cases of infertility. Semen that is defined as a complex fluid containing sperm, cellular vesicles and other cells and components, could immunize the female genital tract. This thesis is related to female immune infertility, in particular to female iso-immunization. The better understanding of this pathophysiological event consists of (1) the determination of antibody isotype playing a significant role in this disease, then (2) the characterization and identification of semen antibody-binding proteins, seminal and/or sperm, (3) the proposal of potential diagnostic markers to adapt specific therapy and, in addition, the design of miniaturized diagnostic tool based on the selected markers, (4) the suggestion of potential immuno-intervention. Based on the distribution of seminal/sperm-specific antibody isotypes, we suggest that immunoglobulins E, M, A1,2, G3 are not involved in the primary pathophysiological female sensitization. IgG4 appears to be the major subclass interacting with sperm proteins. On a contrary, IgG1 seems to be the one mainly involved in the reactivity towards seminal proteins. We have also extended the existing group of IgG-binding sperm proteins, among which heat shock protein 70 1A/1B, heat shock cognate protein 71 kDa and alpha-enolase have been shown, for the first time, to be related to female iso-immunization. We have put the emphasis on the role of seminal proteins in iso-immunization and not only in the IgE-mediated semen hypersensitivity as known so far. In particular, prostate-specific antigen, prostatic acid phosphatase and zinc finger protein 778 have been determined as immunodominant among IgG-binding seminal proteins. The determination of female serum seminal/sperm-specific IgG subclasses could make the patient diagnoses more comprehensive. Anti-seminal/sperm IgG1,4 might be of interest for immunotherapy. Furthermore, the herein described proteins could be useful biomarkers of such pathology. The miniaturized chip could be a lateral flow immunoassay-based device acting on the immunochemical detection of specific antibodies. The intended immuno-intervention could consist of the effect of intravenous immunoglobulins.

The World health Organization reports infertility as a disease and a failure of reproductive tract to achieve pregnancy after 12 months or more of regular unprotected sexual intercourse. Nowadays, infertility has become a common life phenomenon affecting 1 out of 5 couples at reproductive age. Idiopathic cause is mostly associated with active immune system which may produce high levels of anti-seminal and/or anti-sperm antibodies. Auto-immunization as well as iso-immunization has a significant role in up to 30% of reported cases of infertility. Semen that is defined as a complex fluid containing sperm, cellular vesicles and other cells and components, could immunize the female genital tract. This thesis is related to female immune infertility, in particular to female iso-immunization. The better understanding of this pathophysiological event consists of (1) the determination of antibody isotype playing a significant role in this disease, then (2) the characterization and identification of semen antibody-binding proteins, seminal and/or sperm, (3) the proposal of potential diagnostic markers to adapt specific therapy and, in addition, the design of miniaturized diagnostic tool based on the selected markers, (4) the suggestion of potential immuno-intervention. Based on the distribution of seminal/sperm-specific antibody isotypes, we suggest that immunoglobulins E, M, A1,2, G3 are not involved in the primary pathophysiological female sensitization. IgG4 appears to be the major subclass interacting with sperm proteins. On a contrary, IgG1 seems to be the one mainly involved in the reactivity towards seminal proteins. We have also extended the existing group of IgG-binding sperm proteins, among which heat shock protein 70 1A/1B, heat shock cognate protein 71 kDa and alpha-enolase have been shown, for the first time, to be related to female iso-immunization. We have put the emphasis on the role of seminal proteins in iso-immunization and not only in the IgE-mediated semen hypersensitivity as known so far. In particular, prostate-specific antigen, prostatic acid phosphatase and zinc finger protein 778 have been determined as immunodominant among IgG-binding seminal proteins. The determination of female serum seminal/sperm-specific IgG subclasses could make the patient diagnoses more comprehensive. Anti-seminal/sperm IgG1,4 might be of interest for immunotherapy. Furthermore, the herein described proteins could be useful biomarkers of such pathology. The miniaturized chip could be a lateral flow immunoassay-based device acting on the immunochemical detection of specific antibodies. The intended immuno-intervention could consist of the effect of intravenous immunoglobulins.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2005. / Härtill 5 uppsatser.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 4 uppsatser.

Thesis (Ph.D.)--Brandeis University, The Heller School for Social Policy and Management, 2005. / Chairperson: Jon Chilingerian. Includes bibliographical references.

This study explores the experiences of infertile married African women in South Africa. The study explores the women’s emotional experiences, their experiences of their relationships and the possible ways in which their culture may have influenced their experiences. The literature review gives an overview of female infertility, motherhood and feminism- from its conception to its current status in South Africa. The study is carried out in a clinical setting where the participants are already attending an infertility clinic for treatment. Six black women participate in this study and they are all married and experiencing primary infertility. This study does not include women experiencing secondary infertility because although they may presently be infertile, they have previously experienced one or more successful pregnancies. Therefore, primary infertility is chosen as the focus of this study because unlike secondary infertile women, primary infertile women have never experienced pregnancy and childbirth and thus their infertility is more noticeable and severe. The study is qualitative in nature and it is conducted within a feminist social constructionist research paradigm. This research paradigm is deemed to be more relevant in researching an issue pertaining to women, because feminist research enables social scientists to explore women’s social history, women’s perception of their own situation, their own subordination and their own resistance (Mies, 1993). Through social constructionism, the women are each able to make meaning out of their experiences and to include the influences of their culture, gender and social context in the construction of their experiences. Furthermore, since feminist research perspectives have supported the process of telling sensitive human stories as research, a narrative approach is employed in gathering information regarding the women’s experiences of being infertile. Thus, through telling their own self-narratives, the women are able to relate their experiences as well as the events that took place in their lives regarding their infertility. Structural narrative analysis as well as content narrative analysis are employed in the analysis of the women’s narratives. What emerges from their stories is the hope and the subsequent disappointment that follows from their countless visits and consultations with different health professionals, both western and traditional, as they search for pregnancy. It also emerges that in addition to their personal experiences, these women’s marital and familial relationships, as well as their extended social relationships, also contribute to the emotional distress that they experience as a result of their infertility. Although most of the women mainly report negative experiences, there are also some who report positive experiences and some form of support in their lives. It is hoped that the results obtained from this study will enable psychologists to intervene effectively and to work collaboratively with other health professionals towards delivering services aimed at assisting infertile African women medically, socially and psychologically. / Dissertation (MA (Clinical Psychology))--University of Pretoria, 2008. / Psychology / unrestricted