Cross-cultural comparison of fertility specific quality of life in German, Hungarian and Jordanian couples attending a fertility center

In total, 144 German (response rate: 81 %), 126 Hungarian (response rate: 43 %), and 126 Jordanian (response rate: 81 %) couples agreed to take part in the study. We had to remove data of 21 German couples because questionnaires from one or the other partner were missing. Our final sample contained a total of 750 participants from Jordan (N = 252), Hungary (N = 252) and Germany (N = 246).

Table 1 shows the sociodemographic and medical variables for women and men in the three samples. German women were older than Hungarian and Jordan women, whereas Hungarian men were younger than their counterparts in the other two countries. While the length of relationship was shortest in Jordanian couples (and longest in German couples), Jordanian couples reported the longest duration of wishing for a child and of undergoing through infertility treatment. At the same time, couples already having child(ren), were overrepresented in the Jordanian group (compared to the German and Hungarian groups). In Jordan, both men and women had high levels of education. Hungarian women had high levels of education, too, but not significant compared to the other two samples. With more than 40%, Hungarian couples were more likely to be in the diagnostic process or have a diagnosis of unexplained infertility (compared to about one quarter both in the Jordanian and in the German sample).

Gender differences (within-subjects differences) on the FertiQoL subscales were observed in the emotional and mind/body quality of life domains; men scored higher on these subscales than women in all of the three samples (Table 2). In Hungary and Jordan, men also reported better social quality of life than women. Thus, gender differences in emotional, mind/body and social domains were confirmed in within-subjects pairwise comparisons of repeated-measures ANCOVAs as well. In our study, the subscales of FertiQoL proved reliable with Cronbach’s alpha ranging between 0.60 and 0.89 for each country.

Cross-country differences (between-subjects differences) in FertiQoL-subscales are presented in Table 3. First, we found marked differences between the couples of the three countries in emotional, mind/body and relational quality of life domains; Jordanian participants showed the lowest scores, Germans scored higher than Jordanians, and Hungarians scored even higher than the other two groups. After these results were controlled for the relevant sociodemographic and medical variables such as age, educational level, duration of relationship, duration of child wish, duration of medical treatment, type of diagnosis and already having child(ren) as a couple, differences between Germans and Jordanians disappeared in all subscales, except for the emotional QoL. On mind/body and relational FertiQoL-subscales, Hungarian reported better QoL than Germans and Jordanians, even if the results were controlled for sociodemographic and medical variables.

We observed differences when country was taken as between-subjects factor: on emotional and social scales, the country accounted for 10 % of the variance of QoL-differences. The impacts of covariates were significant only in some cases. Therefore, age of woman was found to be a significant mediator of differences in domains of mind/body (F(2) = 5.4, p < 0.05, PES = 0.01) and social quality of life (F(2) = 3.9, p < 0.05, PES = 0.01).

We excluded the possible tendencies for generally scoring extremely high in the Hungarian sample or extremely low in the Jordanian sample because general quality of life (as measured with FertiQoL AB; calculated by the means of FertiQoL A and B items) was rated significantly higher by Jordanian couples than by Hungarian couples.

In order to see our results in a broad international context, we collected all recently published data of FertiQoL studies with clinical samples of women from different societies [11, 14, 16‐18] and used them to construct a graph of the FertiQoL total scale by country for an extended international comparison (Fig. 1). The results from one study were not included in the graph because of methodological concerns: an analysis of a Taiwanese sample had too poor reliability coefficients, so we did not consider that results [16]. Boivin et al. [11] reported scores of both online and clinical samples, but we included only the scores of the clinical sample (only available for women and men combined). As seen in Fig. 1, fertility specific quality of life especially in German women appears to be in accordance with the data for English speaking, Dutch, Turkish, and Spanish samples. This graph confirmed that FertiQoL can measure similarly the effects in clinic populations of infertile women from different countries.

The main finding of our study is that cross-cultural differences in experiencing primary and secondary infertility related quality of life are not as pronounced as expected. German and Jordanian infertile couples showed quite similar fertility specific quality of life but QoL in Hungarians was high compared to their counterparts from the other two countries. At the same time, the significantly lower quality of life on the emotional FertiQoL-subscale among Jordanian couples (compared with the other two samples) partially supported our hypothesis based on the assumption of a more pronounced pronatalist culture in Jordan. The Jordanian social norm of expecting to have a baby soon after the marriage was obviously reflected in our study, as Jordanian couples exhibited the shortest time living in their marriage. At the same time, they were wishing to have a child and being treated for infertility for the longest time compared to the other two samples.

At the first sight, some cultural differences between the countries were apparent, but the in-group differences were greater (e.g., in the Jordanian sample). In this group, couples exhibited with a broader range of age, relationship duration, duration of child wish, duration of medical treatment. Both partners were located on a broader spectrum in almost all fertility specific quality of life domains (especially on the Emotional and Mind/Body sub-scales), as depicted by the range of standard deviations in the FertiQoL scores of the Jordanian sample (not tested for significance).

Edelmann and Connolly [24] demonstrated that gender stereotypes may be common in studies on the adjustment to infertility and may conceal the real reactions of genders. When the relevant sociodemographic and medical variables were controlled between these countries in the analysis of the couples as a unit (and not of group differences of women and men), the “collectivist” vs. “individualist” dichotomy, while exploring cultural differences, disappeared. This “dichotomy” assumption may lead to incongruent conclusions, and therefore we have to focus on intra-cultural differences at a local level in each country and not on intercultural differences.

Hungarian couples had a higher level of fertility specific quality of life in comparison to Jordanian and German couples. It is an interesting observation in the study which might have several causes: With regards to our results, the GLOBE study [25] (especially with the two sociological scales gender egalitarianism and uncertainty avoidance) might provide help in interpreting the data. This worldwide study examined societal and organizational attitudes and practices in 62 cultures. Gender egalitarianism is defined as “the extent to which a society minimizes gender role differences and gender discrimination” [25]. Hungary stands at the second best position out of the 62 countries studied. This means that practically more life roles are offered to women to fulfill and thus they may not feel under a great pressure to become a mother [26]. According to the definition, uncertainty avoidance is “the extent to which members of an organization or society strive to avoid uncertainty by reliance on social norms and bureaucratic practices to alleviate unpredictability” [25]. Hungarians reported on this scale a good tolerance against uncertainty. In this sense, high quality of life regarding fertility problems might reflect that Hungarian infertile men and women could endure better the stress and unpredictability of infertility than Germans or Jordanians. If we consider these explanations, it underlines the necessity of an integrated psychological and sociological approach toward infertility. This points out that viewing fertility specific quality of life as a solely psychological phenomenon is not enough to understand the psychosocial complexity of infertility in different sociocultural settings.

Furthermore, we have to consider other aspects related to the situation of Hungarian couples. The current law in Hungary provides the patients having health insurance with diagnostic procedure—five times through IVF-treatment or six times with insemination treatment—free of charge in fertility clinics under contract with National Health Insurance Fund (OEP). Medications up to 70 % are also supported by OEP [27]. In Germany, health insurance companies cover the costs of diagnosis up to 100 %, although, the costs of treatment and medication are covered, depending on the insurance, at rates of between 50 % and 100 % [28]. In comparison, infertility treatments and investigations are not or are only partly reimbursed by health insurance in Jordan [29]. On the basis of these data, we may assume that financial burdens strengthen psychosocial burdens, at least in Jordan.

At the same time, we have to take into account that the response rate in the Hungarian subgroup was low, so we cannot exclude the possibility that only couples with good adjustment to infertility agreed to participate.

The study has several strengths. To the best of our knowledge, this is the first study to use an internationally validated disease-specific measure assessing fertility-related quality of life in three different countries. The sample sizes are sufficiently large and the study consists of couple-based data.

However, there are some limitations. There might be some sampling bias due to the high rate of refusal to participate in the study in Hungary, and the non-representativeness in Jordan and Germany, where only one university-based clinic was included, respectively. Therefore – and also because we studied convenience samples and not random samples – we cannot clearly postulate that the differences we found between the three samples represent differences between the three countries populations. Furthermore, the Jordanian sample was quite heterogeneous, e.g., duration of treatment ranged from the beginning to long-time therapies or to large time lack between two investigations. In further investigations, sample sizes should be increased by involving more clinics in each country in order to form specific subgroups according to sociodemographic characteristics and medical diagnosis groups. Especially, novel study designs and particular recruitment strategies have to be developed to investigate the experience of infertile individuals not attending fertility clinics. This could also help to distinguish the experience of infertility from the experience of infertility treatment.

For future studies in this field, we also suggest specifying further the sample characteristics focusing on sociocultural aspects in detail and not on psychological variables only. Religiosity, familial and economic status can play important roles in shaping the experience of infertility [30]. Future research could explore if there are larger or smaller differences between countries among men or women, because infertility can have different social meanings for men or women in different countries.

Our results invite infertility counselors to reflect on their own stereotypes regarding the different cultural subgroups of infertile patients. As Hynie and Burns have pointed out, one cannot assume that a cultural norm is descriptive of every member of a given population. “Even countries that appear culturally homogenous are multicultural to some degree, requiring an awareness of diversity issues and the impact of culture on the provision of infertility treatment and infertility counseling” ([6], p. 79). It is recommended that counselors explore the individual couple accurately, attending to their infertility story, their human and financial resources [31], and whether they are supported by the family or the community they belong to, or which specific social expectations they have to meet. Infertility counselors should be attuned to the intra-cultural and inter-individual diversity in the experience of infertility.

This study highlights that sociocultural differences in experiencing infertility might not be as pronounced as previously assumed in contrast to intra-cultural differences. Our aim was to carry out in a cross-sectional study, at a multinational level, a comparison of psychosocial factors in samples of infertile couples who are seeking medical help using an internationally developed infertility specific measurement. We considered not only cross-country but other possible sociodemographic and medical cultural-related variables (e.g., age, education, duration of child wish, etc.). Cross-country differences were detected in the emotional quality of life domain between Hungary, Germany and Jordan, but not in the other FertiQoL-domains. Thus, we suggest that adjustment to infertility should be examined in the specific cultural context, as well, and the focus of future research on infertility specific quality of life should lie explicitly on subgroup and individual levels within a given society and not on group comparisons between countries alone. Intra-cultural psychosocial differences in experiencing infertility seem to be more important for the individual patient than intercultural differences. These findings underline the hypothesis that infertility is also socially constructed [32] and that its meaning is shaped e.g. by gender ideology, importance of parenthood, treatment options, social policy and cultural stereotypes [33].