Qualitative study regarding the ethico-psychological implications on medically assisted human reproduction in Romania
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Rom J Leg Med [26] 447-452 [2018]
DOI: 10.4323/rjlm.2018.447
MEDICAL ETHICS, SOCIAL SCIENCES AND
© 2018 Romanian Society of Legal Medicine HUMANITIES
Qualitative study regarding the ethico-psychological implications on
medically assisted human reproduction in Romania
Mihail Adeodatus Ungureanu1, Vasile Astărăstoae1,*
_________________________________________________________________________________________
Abstract: Infertility is a major public health issue, both in Romania and in Europe. The negative natural growth is also
determined by infertility. That is why we are witnessing a massive development of assisted human reproduction technology and
there arises a need to understand the complex psychological impact of such technologies on the couples, on the children born
using these procedures and on the society at large. This study is a qualitative research on infertile individuals. The lot comprised 8
women and 3 men diagnosed with infertility and a control group of 5 women who gave birth to children without medically assisted
human reproduction (MAHR). It was assessed that the diagnosis of infertility triggers psychological modifications (feelings of
helplessness, anxiety, fear, depression) both at the level of the individual and at level of the couple. While the recourse to treatment
using assisted human reproduction technology solves the problem of infertility, it fails to address all the psychological issues and
sometimes it creates feelings of culpability related to the use of such techniques.
Key Words: Infertility, medically assisted reproduction, ethics, emotional conditions.
INTRODUCTION know that the baby is not the couple’s, for fear of being
stigmatized” [Van Balen, Gerrits, 2001]. Due to social
There are numerous qualitative and quantitative prejudice, infertility is considered to be a women’s, not a
studies regarding infertility in women, but very few of men’s problem. Moreover, when the decision to call on a
them focused on the psychological problems related to treatment center is taken, the tendency is that couple be
the diagnosis of infertility [Ranjbar, Moghadam et al., invited directly to in vitro fertilization (IVF), skipping the
2015]. Upon determination of the diagnosis of infertility preliminary steps, that is the determination of the cause
in a couple, acceptance is hard, regardless whether it’s the of infertility and the presentation of other treatment
woman or the man. It is shown that it is usually perceived methods, leaving the IVF as the last resort. The people
as a collapse of all future plans. This is especially true in taking part to the conception and birth of a child using
case of career women, who see their dream unfulfilled, IVF form a group called “family complex”, a relational
meaning that although they have been successful system in which each child will ask, at a given moment,
professionally and materially, they failed on a personal three questions: am I different? Whom do I belong to?
level, which leads to trauma. For infertile women, Who am I? [Van Balen, Gerrits, 2001]. These people
trauma is aggravated in Romania by the fact that they experience strong emotional conditions of depression
are “excluded from social events and ceremonies, being and anxiety, their personal difficulties affecting, in turn,
considered as “evil beings” They are blamed not only their extended families.
by their spouses, but by the entire family, as well. Some The progress of the medical technology also
of the men choose to leave their infertile wives. That is raises ethical aspects related to what is just, what is good
why when the couple resorts to MAHR and donors, the and what is fair in the doctors’ and patients’ behaviors
secret must be kept strictly so that the world can never as well as in the society. An individual’s fundamental
1) “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
* Corresponding author: E-mail: astarastoae@gmail.com
447Ungureanu M.A. and Astărăstoae V. Qualitative study regarding the ethico-psychological implications
rights derive from the recognition of their human status, attitudes that an individual usually hides. This research
dignity, inviolability of their life and from the fact that is not to be seen as invasive when access is allowed
the individual was born free and will always be free. An and when the individual has a genuine need for the
individual’s involvement or participation to the process of information they wish to learn [Dafinoiu, 2002: 44]. The
decision taking regarding their own body or health need complex questions the qualitative research addresses aim
to be recognized as universal rights [Carmi, 2007: 5-7]. at knowing, from the perspective of infertile people, the
The informed consent is a process by means of which modalities to experiment and to act in relation to these
the investigator/researcher communicates to the patient/ new state of the art medical technologies. Compared to
subject relevant information on the clinical treatment/ social sciences, where the qualitative research is used
study they are invited to be part of and has become the more frequently, in medicine this method is understated,
modern clinical practice of trust, following which the which keeps certain crucial information unrevealed.
patient/subject expresses their consent or refusal to take Failure on the part of infertile people to fully understand
part in the study. Furthermore, it is also an issue of social the consequences of using these techniques can lead to
responsibility in medicine, which raises the problem of psychic traumas that are hard to heal. The approach of
reforming the health system. this subject is also motivated by the fact that the studied
phenomenon exists and the theme is of interest in the
MOTIVATION AND PURPOSE OF THE scientific community to attract the attention of as many
RESEARCH specialists in the field as possible; furthermore, the theme
has deep implications for the society as well. The interview
The purpose of the qualitative research is “to method was used for this qualitative research, which was
study people in their natural environment, in their day- described, as early as 1926, by the Swiss psychologist
to-day life. This research aims at finding out the way Piaget who argued that the use of the clinical method
people live, talk and behave, as well as the things they of the interview represents the “clinician’s art, which
enjoy and bother them; it aims especially at knowing the consists not in triggering answers, but in encouraging
meaning their own words and behaviors have for people" free speech and in discovering spontaneous tendencies,
[Agabrian, 2004: 18]. As far as this study is concerned, instead of channeling or retaining them [Curelaru, 2007].
the purpose of the qualitative research is to gather The clinical method in a Piagetian interpretation is based
information from each participant related to their special on a free conversation where a theme directed by the
feelings associated with the diagnosis of infertility. The interviewer is chosen, where the interviewer follows on
study looks for significant elements and analyzes the the answers, asking the interviewed individual to justify
similarities and differences between then and determines their words and explain the problem they are facing
the way these elements can fit into research categories, [Curelaru, 2007].
seeking to “increase the comprehension of a phenomenon, Only part of the results is presented in this
to describe the data in as much detail as possible to allow article. The type of standardized interview was used,
their subsequent transfer to other situations [Agabrian, the number and order of questions are constant for the
2004: 54]. The reasons for a qualitative interview study lot. The major advantage of this type of interview
regarding infertility are determined by the existence, in is the “comparability of answers and content analyses
Romania, of a certain reluctance to call on reproduction of maximum accuracy and validity [Curelaru, 2007].
techniques; many infertile people fail to resort to such For this study we used the directed interview, where
techniques invoking religious reasons; there is also a the “interview guide looks like an open-question
lack of information regarding the procedures of artificial questionnaire, the difference being that the answers
insemination, in vitro fertilization, the effects of using are oral and recorded as such. The operator cannot
the technique and the genetic risk related to them; modify the form of the questions, their number or
mistrust in the clinics in Romania is prevalent, leading to order [Curelaru, 2007]. In carrying out our study we
a phenomenon of “medical tourism”, that involves large used the method of “research clepsydra” which consists
amounts of money. in: general question – hypothesis – observations – data
analysis – results – conclusions. The hypothesis is a
METHODOLOGY OF THE RESEARCH “specific prediction statement that describes in concrete
terns what we expect to get from the study [Curelaru,
If qualitative methods are a horizontal analysis 2007]. As the specialized literature in the field of
(the intention to find out the same things from a investigation indicates, two types of reasoning are used:
large number of cases, which involves many people), deductive and inductive reasoning.
quantitative methods involve a vertical analysis, using a For this research we opted for the inductive
limited number of people, with the intention of finding reasoning, which was used to find solutions to the
as many things as possible from each subject, capturing problems identified in case of infertile individuals,
“significant information by identifying feelings and since in the “inductive analysis the facts are observed
448Romanian Journal of Legal Medicine Vol. XXVI, No 4(2018)
and recorded, then analyzed, compared and classified bothering her. After she gave birth (experiencing huge
[Scarneci, 2007:17]. The inductive process by which the traumas), she wants to be considered normal (as in giving
analytical categories are identified based on the data is birth using normal means): “I want to live a normal life
known as grounded theory. The term starts from the idea and to be treated normally." For subject 2, the sincerity
that hypotheses are formulated starting from the data she displays when speaking about her desire to have
collected in the field [Cucu-Ciuhan, 2005: 82].The idea children is obvious. There appears, however, a feeling of
is that theories should be based on empiric research, not guilt and blaming of the self: " maybe it would have been
the product of abstract research [Cucu-Ciuhan, 2005: better to get married sooner and have children right after
95]. The method is an approach oriented on the interest marriage."
of an individual case [Scarneci, 2007: 34].The cases with The following question attempted to reveal
similar answers (similar behavior) are examined to see the way in which the duration of infertility influences
the conditions they have in common to reach a correct women’s psychology:
theory at the end of the analysis. The answers of the 2. Did you try to have children in the first days
interviewed are important “due to the way aspects of of the marriage or relationship with your partner of
reality are built” [Silverman, 2004: 115]. opposite sex?
Answer:
RESULTS AND DISCUSSIONS (A) Yes, we tried in the first days of marriage or in
the period right after marriage to have a child, because at
This article introduces straightforward, profound that time we were both ready to have a child, as a family.
question. This article introduces straightforward, We had a 7 years’ relationship prior to the marriage, when
profound questions related to the problem of infertility we completed our graduate and post-graduate studies,
for only two female subjects, one who gave birth using focused on our professional development and didn’t want
IVF (A) and another one who is trying to give birth to to have children.
children (B). (B) No. I was busy with getting a house, with my
For the beginning, we wanted to find out how the job…
diagnosis of infertility was perceived and how it modified Analysis:
their lives. The question was: For subject 1: The subject forgets too quickly
1. Are you affected by the problem of infertility the 7 years of relationship when the couple didn’t want
in your day-to-day life? What impact does fertility have children (probably filled with abortions as well, that
on you? influence future conception). The answer is truly positive
Answer: after they got married, meaning after seven years of
(A) It doesn’t affect me at all in my day-to-day sexual intercourse without the desire to have children
life. Only few people in my family know the facts and because they were mainly focused on their “professional
the problem of my infertility. I didn’t want to make this development”. For subject 2, one can also identify a
aspect of my life public to avoid being categorized by the straightforward admission of the fact that the “house and
others or becoming a topic of interest. I want to live a job” came first, not the children. The feeling of culpability
normal life and to be treated normally after I gave birth is more obvious with subject 2.
using IVF. The desire to have children may appear later
(B) The fact that I still don’t have children affects in the couple’s life and is influenced by socio-economic
me. It makes me think about the past (maybe it would factors.
have been better to get married sooner and have children 3. If you believed you didn’t have to have children
right after marriage). It torments me sometimes to see when you were younger, did you think that maybe, later,
mothers carrying their babies, when people ask me why I it would be much harder to have children?
don’t have children or when I am going to have children. Answer:
I think I’m asking myself: why me? Why doesn’t any (A) I am 36 now. We first tried to have a baby
child want to choose me as a mother? Why doesn’t God when I was 29. We had our baby when I was 34. At 29,
want me to have children? Rationally speaking, I think I when we started trying to have a baby, I didn’t think
understand the situation and I would take measures as it was too late and I didn’t expect it to be harder than
quickly as possible to adopt a child. when I was 24-25, when maybe we could have had a baby
Analysis: after having completed part of our studies. Now, with
For both subjects, the diagnosis of infertility hindsight, when I think about what we’ve been through
constituted a trauma they tried to hide. However, there to have another child, maybe it would have been better
appear differences at a later stage. For subject 1 we not to put professional experience and studies first and
can notice that when the treatment started, she was in have children sooner.
a state of hostility towards people who were not close. (B) Yes. The battle of conceiving a child at a later
She was trying to hide the problem of infertility that was stage is harder and takes longer.
449Ungureanu M.A. and Astărăstoae V. Qualitative study regarding the ethico-psychological implications
Analysis: for religious reasons allegedly, shows that she is not fully
Both subjects show regret for not having aware of the Church’s position on the matter (Orthodox
conceived children at an optimum age and focused on Church – as the patient is Orthodox), which approves
other aspects, especially their career. the IVF, provided a maximum number of 3 embryos are
Compliance based on the trust in the treating conceived and taken to birth). Then, the fact that she is
doctor is an essential element in treating infertility. On not familiar with the method of artificial insemination
the other hand, doctors should also adopt a responsible makes us think that she was not given all the information
way of approaching the diagnosis and the treatment. related to MAHR, which means that information should
4. Have you considered the advice and therapeutic be very well detailed.
measures recommended by the specialist The individual responsibility towards the fate
Answer: of supplementary embryos was tested by means of the
(A) Always. I followed all the doctor’s following question:
recommendation regarding the investigations we had 6. Do you know that using the IVF/ET technique
to do, I followed the treatment and reported for all there remain several embryos? What is your decision in
the necessary appointments. In the period during the this matter?
treatments I went to visits monthly. I respected all the Answer:
doctor’s indications because he is the only one able to (A) Following the first IVF there were 2 embryos
treat us and solve our problem. left that we froze and than had them transferred during
(B) Yes and no. Several years ago I went to a another cycle. I didn’t get pregnant following this embryo-
doctor who recommended some very expensive tests I transfer.
couldn’t have afforded, so I didn’t do them. (B) Yes. I know several oocytes are collected for
Analysis: insemination. And I know that only part of the embryos
The first subject had a good relationship with are implanted. First of all, I wouldn’t resort to such a
her doctor and understood that she needed to observe technique. I wouldn’t want to have on my conscience the
the indications and also bear the costs. Undoubtedly, souls of some babies experiments are being made with or
the doctor’s attitude influenced the patient’s behavior. In who are reproduced in the lab to become organ donors.
case of the second subject there appears an uncertainty Analysis:
regarding the relationship with the doctor and the The first subject, using MAHR, accepted the
information and options communicated by him. The cryoconservation of two redundant embryos, showing
“yes and no” answer shows that the patient was not fully approval with this procedure. The fact that the embryos
satisfied with the information she received and then didn’t survive after de-freezing tells us that many
showed her discontent about “very expensive” medical embryos are destroyed during the process [Harper et
tests, hence the search for other solutions, among which al. 2012], which is why their cryoconservation should
medical tourism in another country, with lower prices for be avoided. Subject 2 confirms the fact that she fails to
such procedures. resort to MAHR/IVF due to religious reasons, but she is
The acceptability of medically assisted human right when she states that embryos have souls and that
reproduction technologies varies and is influenced by the experiments are conducted or they are conceived in the
social environment and culture. lab as donors for “material” (bone marrow, for instance),
5. Would you agree to use MAHR techniques to as such cases were reported.
have children? A new question was used to analyze this issue in
Answer: more detail:
(A) Yes. I passed all these stages and I managed 7. Would you donate your gametes to close
to remain pregnant only following the forth IVF with relatives or friends?
ICSI. Answer:
(B) This technique involves several methods. (A) I don’t agree with this procedure, even if
There are some I completely disagree with (in vitro they asked for it. I do not want to donate my genes or
fertilization, gamete transfer, intracytoplasmic injections). my husband’s genes as genetic material for relatives or
There is one method, however (artificial insemination) I strangers.
don’t know how I feel about. (B) I wouldn’t do that.
Analysis: Analysis:
For subject 1, the positive nature of the “Yes” The sincerity and firmness of both answers is
answer shows that the patient experienced the complexity worth noticing. These straightforward answers should
of the treatments and that “only” during the fourth cycle be considered when a law is passed on the matter. Even
did she manage to procreate, being well-known that each if secular bioethics uses excessively the principle of
cycle is very painful (ovarian hyperstimulation, etc.). For permissiveness, the traditional Christian bioethics should
subject number 2, the fact that she avoids using IVF/ET, be taken into account as well, which fails to approve with
450Romanian Journal of Legal Medicine Vol. XXVI, No 4(2018)
the donation of gametes. 10. Do you agree that the Romanian state should
We stated from the beginning that trust in the cover a part of the MAHR expenses so that you are able
treating doctor is a defining element in the treatment of financially to conceive children using these techniques?
infertility. Answer:
8. Do you trust the doctors from Romanian (A) Yes, the Romanian state should cover, in
maternity hospitals? part or in whole, all the MAHR expenses. Not everybody
Answer: wants to go through these financially and emotionally
(A) Yes, but not all of them. I have always asked consuming procedures. Those who choose to walk this
recommendations for the doctors who treated me. My way truly want children and should be supported by the
parents and doctors, my mother-in-law is a doctor and I state.
have always had guidance from them. (B) Well…people fall into two categories: those
(B) Yes, I trust some doctors after thorough who would resort to IVF and those who wouldn’t. The
research on the internet. The opinions are divided, ones in the first category spend fortunes to have babies.
however. Although our country has state-of-the-art Some even take bank loans to cover the treatment
medical equipment and our doctors are very well expenses or the procedure as such. Now, if the state
prepared, there are two big problems in the Romanian covered some of these expenses, we would have a larger
mindset: the fact that Romanians question the doctor’s number of people who would resort to this method
diagnosis and they will do anything possible to find out but also a larger number of souls conceived in the test
a second and a third opinion to assure them they don’t tube we would never find out about, etc. I would like
suffer from a serious disease. the state to contribute in two directions: to cover the
Analysis: expenses for medical investigations (blood tests, surgical
In case of both subjects one can notice a shade of interventions) and to modify a little bit the adoptions law.
doubt regarding the relationship with the doctor, which Analysis:
shows a lack of complete information on the Romanian The first subject, who resorted to these medical
doctors and also on MAHR in Romania. techniques and was successful – after several attempts
It is a lot more difficult when an opinion is sought and high costs –suggests that the costs (or, at least, part
regarding the medical system. of the costs) be supported by the state, an opinion the
9. Do you think that the current medical system legislator should take into account if they care about
in our country helps your problem? improving natality. For the second subject, there should
Answer: be a clearer stand, of the Church as well, that these
(A) The private medical system in our country reproduction techniques are not evil in themselves and
helped us in our problem. We had the possibility to that all that needs to be done is to find a way to express
investigate and to have a child following multiple the information in such a manner as to cast away the
interventions and treatments conducted in the private fear in using them, of course, with the enforcement of
clinics of our country. The state medical system should the traditional Christian and not secular bioethics. But
encourage the increase of natality by any means and to the state, as subject 2 argues, should at least cover the
promote the MAHR procedures in vast programs to expenses for medical investigations (blood tests, surgical
allow infertile couples to have children. interventions) and to modify a little bit the adoptions law,
(B) I don’t know. this last law truly needing a revision.
Analysis:
The first subject makes the difference between CONCLUSIONS
the private and state medical systems in our country. She
shows that the private system solved her problem, while This study shows that infertile women who
the state system, as the subject argues, “should encourage request treatment are confronted with several psycho-
the increase of natality by any means and to promote the emotional problems with great effects on the mental
MAHR procedures in vast programs to allow infertile condition and welfare of infertile individuals and couples,
couples to have children”. For subject 2, this “I don’t while infertility is often treated as a biomedical problem,
know” is indicative for the doubt regarding MAHR in our without taking into account the patients’ mental,
country, proving the necessity for a complete information emotional, social, and cultural aspects. The results have
guide related to assisted reproduction, both in the private also shown that one of the major causes of psychological
and the state system. stress is social pressure of the community’s members.
The medically assisted human reproduction According to the results, while the medical advertisements
requires a financial effort from the couple. This effort (paid by various more or less legal clinics) for treating
sometimes exceeds the couple’s possibilities. That is why (avoiding) infertility is tempting, its mental, emotional,
social responsibility in the field of health should also be socio-cultural and political aspects are still neglected or
considered in relation to this aspect. underestimated. Due to the fact that the treatment of
451Ungureanu M.A. and Astărăstoae V. Qualitative study regarding the ethico-psychological implications
infertility involves high costs, a difficult challenge for is opted for, it is understandable why the destruction
people from social classes with low income, who cannot of embryos is encouraged, as they are considered as
afford the costs with the psychological counseling, mere cells and not as incipient life from the moment of
this study suggests that it would be a good idea to hire conception (fertilization). Similarly, the state should truly
professional social assistants as complementary assistants support the people who resort to MAHR to conceive
in infertility clinics to manage the problem of infertility children, because natality is decreasing and steps should
under all its aspects. This professional assistance would be taken to eradicate the negative natural growth. We
answer not only the needs of infertile individuals, but also believe that a clear and useful legislation is an emergency,
the needs of the social system in which infertile people to support infertile people. Furthermore, for specialized
live. In this perspective, the social assistants can advocate clinics, it is mandatory to create a guide comprising
the rights and needs of infertile people as a means to very important information from scientific researches,
plan the development by the political decision factors, with the purpose of honestly and concretely assess all
so that infertility can be seen as a bio-psychic social the data related to the emotional conditions and the
phenomenon. medium and long term adverse effects of these medically
The infertile people who use modern medical assisted human reproduction techniques. Therefore, the
technologies should be informed and counseled top medical technologies in assisted reproduction should
before, during and after the use of these reproductive consider the mother’s welfare, as well as the children’s best
technologies, as they can cause a lot of sufferance and can interest and the protection of embryos, who are turning
lead to psychic or sometimes medical disorders, both on into people, therefore being alive.
themselves and on the children resulted from the use of
such technologies. More efforts should be made in this Conflict of interest. The authors declare that
light, especially regarding the counseling of people who there is no conflict of interest.
use state-of-the-art medical techniques in the field of Acknowledgement. We would like to express our
reproduction. The ethical aspects related to the embryos sincere gratitude for the women diagnosed with infertility
resulted following these procedures should also be who agreed to take part to this study, generously sharing
communicated to the patients, who will decide on their their time and energy to help us complete the qualitative
situation, but care should be paid to what kind of ethics interviews.
should be applied. If an ethic unrelated to Christianity
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