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Abstract Societal expectations for procreation often result in infertile couples accessing assisted reproductive technology (ART). In the current state of this technology, the successful outcome of the birth of a child does not always occur. This study contributes to nurses' understanding of what it is like for couples to remain involuntarily and permanently childless after infertility treatment has ended, and aims to bring about change in attitudes and practice towards this group. Literature that acknowledges individuality as well as shared experience for couples who remain childless after infertility treatment is scarce. Health professionals may therefore encounter difficulties in providing this group with appropriate support. This research used a qualitative approach informed by feminist perspectives to gather stories of five couples' experiences of childlessness after accessing ART. Individual conversations with both members of the marital partnership were recorded, transcribed and analysed. The study found that due to the societal expectation of procreation, and the falsely elevated 'success rates' of ART, couples often delayed decisions about whether they should persevere with treatment, hence reducing the possibility of exploring alternative methods of parenting. As well as highlighting the ambiguity of the term 'success', the study suggests that the hope that technology brings childless couples prolongs decision making and simultaneously serves to compound the sense of failure experienced by these couples. The couples' engagement with ART, as well as their inability to conform to the normative family of parents and their biological children, also contributed to periods of isolation. Following the decision to remain childless, the participants found that setting achievable and challenging goals assisted in re-building their self-esteem, and enhanced the process of adapting to their life without children. Although participant couples expressed obvious grief at remaining childless, they also showed resilience by managing attached difficulties and stigmatisation, and by creating positive future outcomes. For these childless couples, the strength of their relationships was seen as critical in the process of overcoming adversity. This study suggests ART clinics should provide more realistic information to individual couples regarding the likelihood of taking home a baby. Further to this, independent counselling support is recommended for couples prior to and during ART treatment, and when this treatment is ceased.

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In der Forschung dient die Hauskatze als Modellspezies für die Entwicklung und Verbesserung assistierter Reproduktionstechniken (ART) für wildlebende Katzenarten, von denen die meisten der 36 Arten auf der Roten Liste für bedrohte Tierarten als gefährdet eingestuft sind. Eine erfolgreich angewandte Methode der ART bei Hauskatzen ist die In-vitro-Produktion von Embryonen. Allerdings gestaltet sich die Übertragbarkeit der Protokolle auf andere Feliden aufgrund speziesspezifischer reproduktionsbiologischer Besonderheiten oft sehr schwierig. Das Ziel dieser Doktorarbeit war daher die Charakterisierung des felinen Oviductins, ein Glykoprotein, welches ausschließlich im Eileiter exprimiert wird und das in mehreren Studien bei anderen Tierarten einen positiven Effekt auf die Interaktion der Gameten, Befruchtung, Teilungsraten und Embryonalentwicklung gezeigt hat. Die feline Oviductinsequenz konnte in der vorliegenden Arbeit vollständig identifiziert werden. Sowohl auf mRNA- als auch auf Proteinebene zeigte sich eine zyklusabhängige Expression von Oviductin im Eileiter mit höchsten mRNA-Kopienzahlen bzw. höchster Proteinsynthese während des Östrus. Für funktionelle Studien wurde eine Methode zur Herstellung eines rekombinant exprimierten Oviductins in E.coli etabliert. Die Anwesenheit des rekombinanten Proteins führte zu einer signifikant höheren Spermienbindung an die Zona pellucida feliner Eizellen. Die Zugabe des rekombinanten Proteins während der In-vitro Fertilisation (IVF) hatte keinen Einfluss auf die Teilungs- oder Entwicklungsraten der Embryonen, allerdings zeigten Blastocysten, die sich aus einer IVF mit Oviductin entwickelten, eine signifikant höhere Expression des gap junction protein alpha 1 Gens, was für eine verbesserte Embryonenqualität spricht. / The domestic cat serves as a model to develop and improve assisted reproductive techniques for wild felid species from which most of them are listed on the IUCN Red List of threatened species. In-vitro embryo production is successfully applied for the domestic cat but adaption to other felids, caused by their diversity in reproductive physiology, is often difficult. The biggest challenge is to create an in-vitro environment as near as possible to in-vivo conditions within the oviduct where final maturation of gametes, fertilization and early embryo development occur. Therefore, the aim of this doctoral thesis was to characterize feline oviductin, a glycoprotein which is exclusively expressed in the oviduct. Several functional studies with other species could show an influence of oviductin on gamete interaction, fertilization, cleavage rates and embryo development. In the present work gene sequence of the feline oviductin could be identified. Highest mRNA copy numbers and protein synthesis were detected during oestrus, indicating a cycle-dependent expression of oviductin in the cat. For functional studies, a method for production of recombinant oviductin in E.coli was established. Sperm-zona binding was significantly higher when recombinant oviductin was present. Addition of oviductin during in-vitro fertilization (IVF) had no effect on cleavage, morula rates or blastocyst development. In contrast, in blastocysts developed from IVF with oviductin, we found a significantly higher mRNA expression of gap junction alpha protein 1, suggesting a higher quality of in-vitro produced embryos.

Background: This thesis is based on a randomised controlled trial comparing the effectiveness of intrauterine insemination (IUI) plus Controlled Ovarian Hyperstimulation (COH) versus in vitro fertilisation (IVF) as the first line treatment option for couples with unexplained subfertility. Subfertility of a couple is classed as unexplained when they fail to conceive after one year of regular unprotected intercourse and when all the standard investigations for ovulation, tubal patency and semen analysis have been found to be normal. It affects 30-40% of couples. The age-old methods of treating these couples have included the empirical use of clomiphene or gonadotrophins to correct any possible subtle defects in ovulation with or without IUI (to overcome any existing cervical barrier to natural conception) or IVF. However, the best treatment options for these couples have yet to be determined. The matter has been made even more controversial by the issue of NICE (National Institute for Health and Care Excellence) guidelines in the UK that suggest IUI be abandoned completely for these women in favour of IVF after 2 years of expectant management. A systematic review of the available literature comparing IUI + COH versus IVF for unexplained subfertility revealed limited numbers of available studies and high clinical and statistical heterogeneity among them. An online survey was also conducted among fertility specialists to establish the general consensus regarding management of such couples. The results revealed a lack of agreement among fertility specialists with regards to the first line treatment of couples with unexplained subfertility. The mixed 8 response to this survey demonstrated the ongoing dilemma among practitioners, much of which was due to the lack of robust evidence. A randomised controlled trial was then designed to examine the effectiveness of COH with gonadotrophins + IUI versus IVF as the first line approach to the treatment of unexplained subfertility (Figure 1). This was the first UK-based randomised controlled trial comparing these two first-line management options for unexplained subfertility.

Philosophiae Doctor - PhD / Infertility is currently a serious problem that is escalating, not only in South Africa, but also worldwide. In Cape Town, a culturally diverse, urban community of approximately 1000 couples are referred to the Groote Schuur Hospital Infertility Clinic annually. Although infertility is primarily regarded as a medical condition, the treatments have emotional effects on infertile couples due to the recurring highs and lows that often accompany treatments. This study aimed to qualitatively explore and understand the emotional and psychological experiences of infertility and its treatments (specifically In Vitro Fertilisation and Embryo Transfer). Social constructionism is based on the premise that realities are not constructed in a vacuum but rather undergo a process whereby the subjective and inter-subjective experiences over time and through cultural processes come to be regarded as truths. These truths become internalised and function as lenses through which we see ourselves, compose and invent ourselves accordingly, making sense of what would otherwise have been chaotic and meaningless experiences. Additional aims were to examine women's experiences of infertility care whilst undergoing treatment and describe their experiences of coping with infertility and In Vitro Fertilisation and Embryo Transfer (IVF-ET). Semi-structured, in-depth individual interviews were conducted with 21 women presenting with primary infertility at a fertility clinic. This study utilised an ethnographic case study design. The results of the study suggested that women perceived themselves as not conforming to a dominant belief system that promotes motherhood as the most important role for women. The women described their 'failure' to fulfill socio-cultural expectations as emotionally turbulent. Some of the psychological responses to infertility included feelings of disappointment, shock, denial, devastation, anger, frustration, sadness, inadequacy, poor self-image and self-esteem. The women's personal accounts of their experiences of In Vitro Fertilisation and Embryo Transfer (IVF-ET) revealed that they found the treatment to be highly stressful, with emotional bouts of anxiety, nervousness, excitement and optimism. A psychological synopsis of infertility and IVF-ET is infertility and IVF-ET presents. The fmdings in this study suggest the need for the incorporation of presented. This diagrammatic representation shows the intensity of the emotional rollercoaster that psychosocial intervention into infertility management. Greater attention to the psychological and emotional repercussions of infertility treatment could lead to a more personalised approach which, in turn, would optimise patient satisfaction and also prepare couples for the demands of the program by informing them about better ways of coping.

The role oxygen plays in the developing ovarian follicle is of interest not only to the field of developmental biology but also to in-vitro fertilisation (IVF) technologists, as oxygenation of the oocyte is considered to be a potential determinant of oocyte competence. Oxygen transport through the developing ovarian follicle, and practical aspects of the analysis of oxygen in human follicular fluid were investigated in this work. Mathematical modelling of oxygen transport in the pre-antral, and antrallpreovulatory follicle revealed a number of interesting findings, Contrary to previous conclusions (Gosden & Byatt-Smith, 1986), oxygen can reach the oocyte in the small pre-antral follicle. Improved estimates of diffusion coefficients through the granulosa cell layer and the inclusion of fluid voidage in this layer showed that oxygen can also reach the oocyte in large pre-antral follicles. The amount of oxygen that reaches the oocyte in the pre-antral follicle is a function of its size and degree of vascularisation. Symmetrically distributed vascularisation is superior in achieving a well oxygenated follicle. However, the large pre-antral follicle will eventually reach a size beyond which it cannot grow without anoxic regions developing. The size at which this occurs is consistent with the size at which antrum formation is observed in human follicles. The model predicts that the follicle can avoid an anoxic state through antrum formation, and shows that the follicle develops in a way that is consistent with overcoming mass transport limitations. The oxygen status of the follicle during the antrallpre-ovulatory phase of growth requires that the volume of granulosa cells be balanced by the volume of follicular fluid. Further predictions suggest that oocyte respiration becomes sub-maximal at follicular fluid volumes below approximately 4m1, vascularisation levels below 38%, or fluid i dissolved oxygen levels below 5.1 ~01%. These values are consistent with observations in the literature. It was also shown that the measurement of follicular fluid dissolved oxygen levels could provide a simple measure of the respiratory status of the oocyte, and this may be superior to the measurement of follicular vascularisation which requires knowledge of more parameters. Methodology for the analysis of follicular fluid oxygen solubility and diffusivity was developed using a Clark oxygen electrode. Analysis of these parameters showed that they are similar to human plasma, and allowed the predictive uncertainty of the model to be reduced. Experimental studies into the effects of IVF aspiration on follicular fluid were carried out. Aspiration results in significant changes in the properties of follicular fluid. Dissolved oxygen levels rose 5 * 2 vol%, pH increased by 0.04 * 0.01 pH units, and temperature dropped by 7.7 * 1.3 "C. Mathematical modelling of blood contaminated follicular fluid also showed that contamination results in significant changes in the dissolved oxygen of the fluid. This suggests that if the composition of follicular fluid is to be determined (particularly dissolved oxygen), sampling andlor measurement of fluid must take place before the collection vial of the aspiration kit, and blood contamination must be eliminated. Based on this result, the design and testing of devices capable of reliable sampling andlor rneasurement of oxygen levels of follicular fluid was considered. This presents a continuing challenge, including the integration of routine follicular fluid oxygen measurement into clinical practice.

Gamete donors are actively searched by companies dedicated to assisted reproduction in the Spanish State, and advertising is not only legal but rather common. This thesis provides an overview of the main themes that arise from the analysis of mostly visual materials used to promote ovum donation in public spaces in Barcelona, and critically links them to current debates in intersectional feminist cultural studies of technoscience, bodily theory and visual studies. Conceptual and affective tensions between characterisations of women’s bodies, reproductive function and desires are identified and brought forward in terms that imply tropes of sacralisation, reification of cells/organs/tissues, and fragmentation of the bodily reality. It is argued that egg donation advertisements use an imagery that deeply connects with practices well rooted in Western biomedical traditions when it comes to female bodies, physiology and reproductive function, and that such practices are to be understood against the backdrop of neoliberalism. The analysis supports the idea that the publicity discourse of the assisted reproduction industry in Spain actively engages in a legitimation of the desire of biological parenthood as a right, in ways that value lives conceived in different circumstances and geopolitical contexts in radically different ways, and that can be interpreted as paving the way to prosurrogacy and/or eugenic positions. Future research is encouraged and directed towards exploring issues of agency, particularly in vulnerable groups such as migrant, poor, uneducated or racialised women. Further research is needed in order to build the foundations of a feminist ethical reflection on reproductive technologies and particularly of ovum donation.