As part of the telephone survey, women were asked a series of questions to ascertain their fertility goals and histories. Women were regarded as infertile if they reported one of three situations: they ever tried unsuccessfully to get pregnant for one year or more, they ever tried for 12 months or more to conceive any of their pregnancies, or they ever had one year or more of unprotected intercourse without pregnancy. We used a lifetime prevalence measure of infertility; women were classified as infertile if they had ever experienced a period in their lives when they fit the medical definition of infertility.
On the basis of these women’s answers to questions about their fertility status, we created six fertility status categories (see ). Of the 580 women who were interviewed, 196 (34 percent) met the criteria for infertility at some point in their life and were asked questions about help seeking. Of the 196 infertile women from the telephone interview, 123 (63 percent) were classified as “infertile with intent to conceive” because they reported that they had tried for longer than 12 months to conceive. Two of the women we interviewed in-depth were comfortable describing themselves as “trying” to get pregnant and thus exemplify women in this category. One of them, a 27-year-old woman whom we will call Lillian,4
had been trying to conceive for about two years. Although she had not yet been to an infertility specialist because of financial reasons, she did not seem very different from the treatment seekers who have been the subject of most clinic-based research. Lillian described infertility as a challenge to her identity: “It’s almost to the point where like you know I can’t even feel being a woman fully without having children. So it really upsets me.” She wanted very much to have a baby, but she felt she was running out of time: “I really feel like my biological time clock is ticking. I just really, really would love to have a child, and I think that I’m at that point right now where I’m ready to call a doctor. It’s the money situation that [makes it so] I can’t.” Members of her church had counseled her that God would give her children when He was ready, but Lillian did not intend to let religious concerns stand in the way of treatment. As she put it, “God wouldn’t allow them to have the medicine if it wasn’t here for a reason.”
Fertility Status Categories, Criteria for Fertility Barriers (FB), and % with Fertility Specific Distress (FSD) Data
Mercedes, a 27-year-old woman with a four-year-old child, also described herself as trying to get pregnant. Although she had not yet been “off the pill” for a full year, and, thus, does not meet the biomedical criterion for infertility, she would have presented herself for treatment had money not been a barrier. According to Mercedes:
We haven’t gone so far as to do the temperature with ovulation and all that kind of stuff. We just kind of count the days and try to time. So I think this last month I was probably the most disappointed, but I know that I don’t want to get myself worked up and worried about it, because I know that’s not a good thing. And we have so much going on right now that it’s like, well maybe, you know, it’s going to happen when it’s supposed to happen. There’s too much going on right now, and you know when we finally settle down is when it will come. So but you know [it’s] in the back of my mind that here’s it been six, seven, eight months and….
Mercedes described her sense of being a person with fertility problems as something that developed gradually:
In the beginning, I really didn’t think about until about once a month. Here in the past couple of months, my best friend just had a baby, about three weeks ago. And then my sister just had a baby too, and a girl at work just had a baby about a month ago. So it’s like, you know, I’ve been around all these babies, and so I think I tend to think about it a little more. And my four-year-old really helps remind me every day here lately because she is always talking about our new baby.
We classified as “infertile without intent to conceive” the remaining 73 (37 percent) women from the telephone interview sample who reported having unprotected intercourse for more than a year without pregnancy but who did not respond affirmatively to the other qualifying questions. The “infertile without intent to conceive” are, then, women who qualify as infertile according to the “12 months of unprotected intercourse” criterion but not according to the “intent” criterion. The “infertile without intent to conceive” were not voluntarily childless; in fact, 90 percent of them were biological mothers. Four of the women from the in-person interviews could be classified as “infertile without intent to conceive.” These women said they were not comfortable with the term trying.
Two of these women said that they had not tried and would not try to become pregnant because they saw pregnancy as something couples should be open to and accept but not try to achieve or prevent. They preferred to describe themselves as “hoping” to get pregnant. Katie, a 26-year-old woman with three children, and her husband Dan, age 27, had been married about six years when we interviewed them. Katie said that she and Dan had not used contraception during that period. According to Katie, “We didn’t really plan any of our children. So they have just been kind of a surprise or like a blessing…. I mean it’s not that we were totally shocked, because I guess I figure anybody that has sex ought to figure that that’s a potential (laughter)___But we just didn’t really intentionally think about it until it happened, I guess.” Dan concurred: “I just kind of let God do what he wants to do. And so if we are going to get pregnant, then we’ll get pregnant, because that’s in God’s plan.” Katie was hoping to become pregnant once more but did not plan to see a fertility specialist. As she put it, “If 1 hadn’t had any kids, then I would probably want to see a doctor, and I would probably do it, trying to meet God half way.” Jennifer, a 29-year-old mother of three, is another woman we would classify as “infertile without intent to conceive.” Jennifer concluded on the basis of discussions with friends about what the Bible has to say about children: that people should let the Lord decide how many children they should have. “We’re Christian,” she said, “Bible believing…. So we just really feel…that God blesses us and opens and closes the womb, and he has a plan for our family. And so we’re just excited about whatever that is.” Her husband Matt, also 29, said that he would like more children but that he did not have a specific number in mind: “Now I don’t want to quit. Because every time we have a child, it’s like, ‘What if we didn’t have this child? We would miss them.’”
Thirty-year-old Marta, a third woman who would fit into the “infertile without intent to conceive” category, reported having a very different attitude to becoming pregnant. Marta told us that she had been in a stable relationship for about three years, during which she regularly had intercourse without contraception. Thinking about it, she couldn’t really explain why she had not using birth control, because she was a graduate student at the time and did not want to have a child. She was also concerned about having a child with that partner. When we asked Marta how she felt when she got her period, she replied:
The sensation is relief. You know, because it wouldn’t have been the ideal situation, that’s for sure. It would have been a bad thing for the relationship; …it wasn’t a good relationship anyway. So there was always relief, but … a day would pass by, or two days would pass by, or the next time that we had sex, I would think about it. I’d think it’s kind of weird that I’ve never gotten pregnant, you know, and it’s been so long, you know, it’s just kind of strange that I never got pregnant.
Toward the end of her relationship with this man, she confided her concerns to her sister, who replied that God was having mercy on her and that she should be grateful she had not become pregnant. When we interviewed her, Marta was about to be married to a different man and told us that she would like to start trying to have a child soon after their marriage.
A fourth woman who fits into this category, Sarah, a 32-year-old graduate student, was married to a man who did not want children. At the time we interviewed her, Sara was back on birth control, but there had been a long period when neither she nor her husband were taking steps to avoid pregnancy. Sarah knew that, because she had endometriosis, her chances of getting pregnant were low. When asked if she thought of herself as infertile, Sarah responded as follows:
It was very much in passing, just sort of a thought that was on my mind, and I really only talked to about two people. I didn’t really explore it; it was a note that I made mentally and went on. So it was, “Hey, you know, so and so got pregnant. Oh, that’s great. Isn’t it interesting that all my friends get pregnant, and I don’t? Ah, you are probably just extra careful….” (laughter)
Our primary focus in this article is on the “infertile with intent to conceive” and the “infertile without intent to conceive.” The other fertility types are described in greater detail elsewhere (Jacob et al. 2007
). It is, however, briefly worth drawing attention to the 56 women who acknowledged a situational barrier and were placed in the “situational barriers” group. Reported barriers included not being able to find a partner who also wants children, having a partner who does not want to have children, having a job that makes it too difficult to have children, not being able to afford children, and having postponed having children until it was too late. Although these women are not our primary focus here, the existence of such women provides further evidence that there are alternatives to the biomedical dichotomy of fertile versus infertile. The existence of these women highlights again the idea that fertility intentions are not characteristics of individuals that remain stable over time but, rather, culturally constructed realities that shift with changing circumstances. The question of how a woman comes to define a circumstance as a situational barrier is beyond the scope of this article.
We have been especially interested in the 73 “infertile without intent to conceive” women who reported that they had 12 months or more of unprotected intercourse without getting pregnant but did not say that they were trying to get pregnant at the time. These are precisely the women who would be counted as infertile in most epidemiological studies, but who are unlikely to be included in studies employing clinic samples. Only by paying attention to women meeting common definitions of infertility but who are not trying to conceive can we begin to unravel the relevance of fertility intent for understanding the identity, experiential, and behavioral concomitants of infertility.
The evidence collected through in-person interviews suggests that women meeting criteria for infertility but without intent to conceive are not a homogeneous group. One would be hard-pressed to decide where to draw the line between intention and no intention. What we see here is a continuum of intention, rather than clearly delineated categories. The categories we have constructed to guide us in our research must be understood as ideal types, rather than as ontological categories. To study the relationships among infertility, psychosocial outcomes, or help seeking, we classify women in terms of their fecundity status for specific analyses, but we make no claim that that there are “really” a certain number of fertility statuses. Instead, we argue that fertility statuses are ambiguous and that no criterion can clearly demarcate the infertile from the noninfertile.