The Spiritual Journey of Infertile Couples : Discussing the Opportunity for Spiritual Care

Infertility is a worldwide public health issue that exerts an in-depth impact on couples, families, communities and the individual. This reproductive health condition, along with fertility treatments, often forces couples to question their purpose and meaning in life, and to begin a spiritual journey. Nursing and midwifery literature describes the care of those living with infertility, but often lacks a clear approach of the spiritual dimension, and diagnosis and interventions may not be effectively addressed. In this paper, we present a discussion about spirituality and the assessment of spiritual needs such as hope, beliefs, meaning and satisfaction in life. In addition, spiritual needs are defined, for both nurses and midwives, and spiritual interventions are proposed for promoting couples’ resilience and spiritual well-being. Spirituality should be considered from the beginning to the end of life. It is necessary to translate this into the development and implementation of both specific policies regarding a spiritual approach and advanced education and training programs for nurses and midwives who care for infertile couples.


Introduction
Infertility is a health problem that affects couples worldwide, regardless of their ethnicity, society, culture or economic status [1][2][3].The complex definition varies across disciplines [4], but is mainly described as a condition manifested through the inability to conceive and to achieve a successful clinical pregnancy after 12 months of regular and unprotected sexual intercourse [5].However, this generally accepted time frame is reduced to 6 months when individuals are over 35 years old [4,6].A primary and a secondary form of manifestation are recognised.Primary infertility happens when there is the inability to achieve conception and to have a successful live birth without ever having a child [7].On the other hand, secondary infertility is the inability to achieve conception and have a successful live birth when individuals have already had a previous biological child [7].This reproductive condition is silently experienced with deep and undeniable repercussions in the essence of self, whether of a man or a woman [8,9].Moreover, being involuntarily childless can defy the sense of one's completeness and wholeness due to the unfulfilled wish of parenthood [10][11][12][13][14][15][16][17][18][19].Although infertility is identified, at first, as a physical problem, it is a broad and holistic experience commonly associated with psychological, emotional and spiritual distress [15,[20][21][22][23]. Being diagnosed with infertility and receiving fertility treatment may induce an additional strain, not only in marital relationships, but also in the societal roles that individuals play [24].Similar to other health conditions, such as chronic illness [25][26][27], infertility is often described as a disease that can affect the sufferers' sense of well-being and life satisfaction [28].As a result, a spiritual crisis may arise, leading couples to question their meaning and purpose in life [21,29].Nevertheless, focus has remained on the physiological and psychosocial aspects of involuntarily childlessness diagnosis and treatment [9,24,29] rather than on the spiritual dimension of living with this condition [21].Spirituality is often described as a poorly explored dimension in nursing and midwifery practice [21], but attempts have been made to overcome some barriers [30].The significance of this life transition within a paradigm of patient-centered care reinforces the need for discussing the spiritual journey of infertile couples [19,31].This paper discusses the opportunities for nurses and midwives in providing effective, holistic care based on the relevant literature.

Living with Infertility
The complex nature of infertility is deeply experienced by most couples [32].It's multi-systemic impact affects the environmental and personal realms of each individual and for some this can manifest as an extreme and traumatic event [32,33], in which couples may face questions concerning the purpose and meaning of life [13].Additionally, a person's perception of adulthood is closely related to their social and cultural background, based on several expectations.Couples are mainly expected to have children, take care of them and to preserve the bloodline inheritance [10].This is a societal expectation in many countries, and though there is ultimately more choice and diversity in modern society, not being able to live up to perceived expectations or norms can affect the couple psychologically and make them feel inadequate.Preconceptions related to becoming a father present men with the implicit duty to generate a biological child in order to perpetuate their genetic heritage [8,34].Men and women's life satisfaction is, therefore, conditioned since early age by the ability to fulfill the expected roles of parenthood [14,18,19].
Being a mother has not only an implicit connotation within society but is also associated with the belief in the sacred nature of motherhood [11,18].Motherhood has been defined as a transcendental state [17,35].The transitional process to maternity is reached through conceiving, carrying a pregnancy and giving birth, and this is compared to an expected spiritual journey [10,17].A review over 20 years of cross-cultural phenomenological research found childbearing is seen as the ultimate achievement of a holistic existence [17].Pregnancy and labor are considered significant rites of passage capable of inducing a meaning and a spiritual transformation, regardless of whether women are committed to a religious belief or not [17,36].Some infertile women have manifested craving not only for the purpose of childbearing and its implicit self-growth, but also being able to connect to other women [16,37].Sharing a similar experience of birth seems to be a way to perceive the wholeness of the events, and to develop a new meaning to what women have similarly experienced in their transition to motherhood [38].The inability of going through this expected transitional process has lead authors to describe infertility as a "non-event transition" [27] and an existential crisis [39].
Going through the process of an infertility diagnosis often means needing Assisted Reproductive Technologies (ART) as a therapeutic strategy to have a biological child [44].Women generally assume the main role in engaging with fertility treatment and care [12,14] however a negotiation also has to be made with the partner and in some cultures with the extended family in order to be able to access professional health assistance and treatment [16].Men take on generally a more passive role in any related medical treatments and in the decision-making process [15,19].This behaviour may not be always appreciated by the woman concerned [12,14,35].
In extreme cases extended family may voice depreciative judgments, insults and aggressive behavior targeting infertile women [10,11,13,14,35,43,52] leading to exclusion from social gatherings [11] or a self-withdrawal from these [12,35,45,50].Infertile couples have often reported not being able to match expectations or to be fully understood by others [10,12,13,15,41,43,45,46]. Connection to friends therefore becomes more sparse or absent [13,33,46].In addition, contact with pregnant women and children are perceived by these couples as a proof of others' fertility and the recall of one's own inability to conceive [10,12,50].This situation may lead to social interaction barriers and to isolation [14].
When pregnancy is finally reached, couples cautiously celebrate [35].Nevertheless, the fear of something going wrong is still deep-rooted and can prevent men and women from recognising themselves as parents and engaging in normal preparation for their child's arrival [35].With successful parenthood comes constant anxiety related to the remaining time to care and to watch over the growth of their child [43].
In many cases, couples' resilience is triggered by the infertility experience that is lived as an opportunity for inner transformation and positive spiritual growth [14,15,41,45,50].After a long time in medical procedures with no child, the burden of treatment leads couples to cease their unfruitful quest and to explore other ways of fulfilling their lives [53].Focusing on their relationship, career, educational projects [15,16,50] or other possibilities such as adoption [10,12,15,16,33,35,41,51] or activities that provide close contact with children [12,51] were seen as realistic goals [50] and acknowledged by some as new purposes in life.

Epidemiological Aspects of Infertility
Infertility is both an intimate reproductive health condition and a worldwide growing health problem [3].In 2010, a total of 48.5 million couples around the globe were dealing with this health problem [3], and researchers believe that these numbers do not totally address the extent of its prevalence due to different definitions across disciplines [4].Inaccurate data has also been associated with the fact that not all individuals with this health concern perceive themselves as infertile, and this may compromise the full assessment [3,24].Moreover, constraints related to the sensitive nature of this phenomenon might compromise couples' infertility reports [3].Despite that, this is acknowledged as a public health priority [1].
Findings from a World Health Organization (WHO) study conducted in a diversified social and cultural sample of 190 countries revealed that 1.9% women experienced primary infertility while 10.5% reported to manifest a secondary type of reproductive health condition [3].This resulted in 19.2 million couples not being able to have a first-born and 29.3 million couples unable to have another child [3].
Several environmental, occupational, genetic and infectious diseases have been identified as the causes of impaired reproduction [1].Both genders are affected in 40% of cases but the most common reasons for reproductive issues are related to gynecologic and other conditions, such as ovulatory disorders (25%), fallopian tubal damage (20%), and uterine or peritoneal abnormalities (10%).Also, in 30% of cases of infertility, causes are unknown [54].This health condition is not only related to physical impairment, but also results from current societal trends [24].For instance, child-seeking behaviour was reported to have decreased between 1990 and 2010 [3].Additionally, the need to reach economic stability, financial independency, a career, and educational goals lead men and women to delay conception [19,35,43].All those factors are reflected in the increasing age of people that get married [55] and in the delay in having the first child, which occurs between 25 and 49 years [3].The advanced age of couples engaging in parenthood is an important aspect in fertility, as it is related to the decreasing physical ability of having a child [56].Concerns towards the unknown future of the world's next generation are raised not only because of the aging population, but also due to the rapid decrease in fertility rates [57], with an estimated reduction of children per women in the years to come [57].

Nursing and Midwifery in this Specific Context of Care
Scientific advances in recent years lead to the development of a variety of health services in addressing infertility as a global problem, and in helping couples to achieve their fullest reproductive health potential [44].An urge to conceive led to the demand not only for medical and surgical treatments, but also for advanced reproduction techniques.Regardless of the growing success of these methods of conceiving, a positive outcome is not guaranteed in all cases, resulting in the pursuit of recurrent treatment cycles [44].These procedures are regulated by specific reproductive protocols and policies in each country [37].But, in 2007, the United Nations implemented protective measures for women's reproductive health [58].Infertility care was therefore included in the Fifth Millenium Development Goal, which was far from being fully accomplished in 2015.The need to improve sexual and reproductive health inequities remain [59].The development of such programs generated the need for an integrated interdisciplinary approach in the fertility care setting.Examples are found in the guidelines released by the National Institute for Health and Care Excellence [54].
Studies conducted with samples of infertile people have commonly focused on the bio-psycho-social and cultural dimensions of living with this health condition [29,32,49,[60][61][62][63].Although sparse, nursing and midwifery literature addressing impaired reproduction is growing, revealing an increasing attention towards care provision, specifically in the ART settings.Advances have been achieved through protocols that are specifically designed to address psychosocial needs [64].Recently, a positive relationship was found between psychological status, the couple's relationship, child-carrying rates, and psychosocial nursing interventions [63].Scholars' attention seems to keep focusing on the emotional dimension of this unanticipated life and health event [65,66], even comprising multicultural samples and socio-economic diversified environments, in both qualitative and quantitative research [24].
A person-centered approach has been underlined as playing a determinant role in the implementation of policies which comprise an holistic approach, such as those including spiritual needs [19,21,31,54].Even with evidence of spiritual needs, such as hope [42], meaning and satisfaction in life [28], a consistent and clear spiritual approach is missing in the infertility care context [21,67].Previous studies reported that women engaging in religious practices have a coping mechanism in transcending spiritual distress [68].These findings reveal the current trend to address spirituality through the lens of religion and religiosity [21,35], but other attributes of spirituality should be taken into account, such as connectedness, transcendence and meaning in life [69].Spiritual needs are known to be influenced by social and cultural aspects, and to be determined by family values, which might influence the choices of treatment [70].Yet, disturbed connectedness to self, to others (to husband or wife, relatives, friends and healthcare professionals), and to a higher power are commonly described in infertile people [24].Early studies have concluded that nurses and midwives should receive specific training regarding spiritual assessment and interventions [71], to support couples through all stages of the journey of living with infertility, from the diagnosis to the treatments and beyond [35,42,53].The aforementioned spiritual distress which may occur in infertile couples [21] is listed as a nursing diagnosis in NANDA International since 1978 [72].This diagnosis has been validated in cancer patients [73], but it seems important to conduct validation studies also in infertile couples.When nurses and midwives diagnose, they are confirming their autonomy in clinical reasoning, which pervades the assessment, planning and interventions based on a person-centered paradigm.Infertility is a specific, vulnerable condition and has a specific context of care, which requires a particular approach, such as that of Patient Centered Infertility Care (PCIC) [19].This is a specific relational model based on the provision of holistic and supportive care, capable of connecting all intervening actors (patient, couples, family, and health care professionals) and environments or contexts (fertility clinic's organization, protocols, policies , communities and countries) to help each in the transition to healing and perceiving well-being [19].

The Imperative of a Holistic and Multidisciplinary Approach
An attempt has been made to understand the wholeness of the couple in this context, but the physical, emotional, psychological, social and spiritual dimensions have been often addressed individually.Researchers have mainly focused on the psychological and social aspects of the lived experience of infertility [24,29,74].The perception of this reproductive issue is affected by both interpersonal and intrapersonal factors [39], and several studies have been conducted in an attempt to define a pattern of human response towards infertility.Examples are found in the established relationship between a positive adjustment to infertility and age, high socioeconomic and educational status, positive self-esteem and internal locus of control, and the relationship between distress and advanced age and low self-esteem [27].Only sparse evidence has lifted the veil and uncovered the presence of a spiritual realm in individuals living with this reproductive condition [20,21].Being a religious woman and having a supportive family was associated with positive coping and with finding meaning in infertile women [39].A full understanding of the phenomenon, as lived by the couple, would not be possible without a holistic view of the interconnection between body, mind, soul and spirit [75].In contrast to the biomedical model, each person is perceived to own specific needs and is capable of affecting and being affected by the environment, in a particular and individual way [75].These assumptions, based on Florence Nightingale's standards, are fundamentals of nursing and health care [76].The ground for holistic nursing care [75] has been established and endorsed by organizations such as the American Holistic Nurses Association (AHNA) [77].All commonly embrace a person's health as a dynamic process and a result of the relationship between the individual and the environment, between the subjective and the objective aspects of the life experience [76].Individuals are seen in their own contextualized life [75] and in a constant balance with internal and external factors [76].A disruption in the balanced interaction of all dimensions may compromise the individual's ability to adapt and to deal with life's stressors [75].Disturbance in the sense of well-being may arise and induce a change on health status towards illness [78].Complex interactions between all of those realms determine the individual meaning, well-being and quality of life [75].This seems to go along with the WHO's established health concept as a state of well-being (physical, mental and social) and not merely the reductionist absence of disease or infirmity [79].Additionally, empirical evidence has demonstrated that the individual's perception of infertility is influenced by the meaning each individual attributes to that reproductive health condition [24].A state of well-being is therefore defied when the expected and desired goal of parenthood is compromised by the diagnosis of infertility [28,39].The subjection to painful procedures, lack of control over treatment outcomes, and social pressure from partners, friends, family and community are described as stressors which may be manifested in mental health conditions such as depression [61,80].Emphasis is therefore placed on an integrated approach [76] provided by holistic nursing or midwifery care, based not only in a scientific, knowledge-based therapeutic relationship, but also in a sensitive and intuitive one [81].Thus, it seems important to encourage the practice of conventional and complementary therapies in a collaborative effort to provide multi-systemic and multidimensional care capable of regaining and maintaining health and preventing illness [75,76,78].A fragmented approach to caring for couples who present with fertility concerns or challenges is evident in the literature along with the need to invest in a holistic health approach [36].The answer to complexity is only possible and continuously reaffirmed by close collaboration among different disciplines [78], as well as an integrated and interdisciplinary approach between all members of the health care team [75,78].The WHO [82] and The Lancet Commissions report [83] provide useful guidelines for interprofessional education as a path to collaborative practice and to reach a transdisciplinary health approach.

Moving beyond Emotional Aspects and Understanding the Spiritual Dimension
Scholars' concerns towards spirituality are mainly associated with holistic understanding of the human being [84].Studies have broadly addressed spirituality in settings of people living in different phases of the lifespan, such as childhood [85], adolescence [86] and adulthood [87,88], with a focus on specific situations of extreme vulnerability, such as chronic illness [73,85,87], intensive care and palliative care [88][89][90].Extreme life events and death experiences are commonly found not only in nursing, but also in midwifery literature.Religious practices frequently emerge in neonatal intensive care units with the awakening not only of an individual's emotional response but also a spiritual one [90].Nevertheless, an increasing body of evidence has raised interest in transitional events like child-bearing, child-birth and parenthood experiences [36,38,91].Those could be seen has reminders that spirituality should be considered from the beginning to the end of life.Grieving, spiritual self-growth, self-awareness, redefinition of self-identity and meaning emerges in every life transition, such as in illness or in a life crisis.
Spirituality has a complex and multidimensional nature [69] and is considered to be a human dimension, innate to existence [84,92], and difficult to strictly define.Spirituality is "a way of being in the world in which a person feels a sense of connectedness to self, others, and/or a higher power or nature; a sense of meaning in life; and transcendence beyond self, everyday living, and suffering" [69].Connectedness, transcendence and meaning in life were therefore identified as the main attributes of spirituality, regardless of a religious affiliation [69].The need to apprehend the subjective nature of this concept led researchers to develop instruments of measurement in specific populations and settings [92].
Although it is recognised by several authors as an essential dimension in life and health, the WHO's definition of health still lacks a full approach of spirituality [93].This gap seems to be related to the biomedical model and the poor development and implementation of policies towards effective holistic care [93].Spiritual well-being is considered by many as the missing fourth dimension of health [94].The way in which the dynamic relationship between personal (self), communal (with others), environmental and transcendental domains occur is reflected in one's spiritual health and spiritual well-being [92].Emphasis in emotional status and psychological well-being has buried spiritual well-being under the cognitive approach of the mind instead of an in-depth understanding of the spirit [92].Findings have proven that defective or absent harmonious relationships between self, others, environment or higher power compromises the wholeness of one's spirit [84,92], and impacts one's psychological health [95].
Similar to biological needs, hope, forgiveness, justice, love, creativity, peace, joy, trust, identity, self-worth, adoration, harmonious relationships, meaning, purpose in life and religious practices are expressions of spiritual needs [92].Not meeting those spiritual needs can create spiritual instability and induce spiritual distress, defined as "a state of suffering related to the impaired ability to experience meaning in life through connectedness with self, others, world or a Superior Being" [89].Therefore, the lack of fulfillment of a fundamental need such as meaning and purpose in life, as perceived by infertile people, may induce spiritual distress in this population [15,18,20,22,35,41,45].If individuals are not resilient or capable of effectively coping with this adversity, self-healing may be compromised and suffering may be manifested through isolation [10][11][12][13]33,35,45,46,50], low-self-esteem [16,33], anxiety [10,15,35,43,48] and depression [33,35,41,47].Those with infertility have also reported using rituals like prayer [10,16,20,35,41,47], meditation [35], attending church, sanctuaries and shrines [16,45,47] in a spiritual path to transcend suffering and strengthen their hope in their parenthood pursuit.Religious practices are commonly addressed as a way for couples to find meaning in life and to prevent hopelessness [15,35], but these are not the only spiritual resources they use.Other non-religious coping strategies are described to help individuals regain some kind of spiritual comfort [20] through becoming persistent and resilient [15] in facing failure and focusing on the positive outcomes of this adverse event [22].
Developments made towards the linkage of healing, health and illness with spirituality are still far from achieving full understanding [69,92].Many links are still unknown and several proposals for further research are still emerging from current literature [93].Many people dealing with infertility are still lacking a spiritual and integrative health approach [21,67].

Opportunities to Provide Spiritual Care
Spirituality is considered an essential aspect of providing holistic and person-centered care [81].A person-centered approach, promotion of self-awareness and empowerment of each person are advocated as principles in assessing and caring for the human being [75][76][77][78].Despite that, diagnosis and interventions are not effectively addressed, and depreciative reports from infertile individuals about fertility services and health staff are commonly expressed [67].An alarming absence of connectedness with health professionals is reported, and the interactions are often described as distant, dehumanised and lacking sensitivity [10,12,19,33,35,41,46,96]. Professionals' concerns towards the biological causes of infertility and its cure makes them focus on the physical condition and treatment procedures rather than on the wholeness of the infertile person or couple [19,41,46].Consequently, a sense of mistrust and humiliation is described by patients along with the sense of their emotional, psychological and spiritual needs being actively neglected [41].Communication [19,33], information [19,33,45,51,96], promotion of realistic hope [33,46], accessibility of care [16,19,33,96], support [18,19,33,41,46], and empowerment [33,46,96] were identified as areas in need of further improvement.These aspects are crucial in the relationship established between staff and patients, and are affecting future interactions between people living with infertility and health caregivers, and the decision-making process.Distant interactions and defective communication associated with the exhausting treatment procedures have been pointed to as one of the main reasons to quit fertility treatment [53].
Nurses and midwives have been identified as having a main role in all In Vitro Fertilization (IVF) processes [19,33].In some cases, their intervention is negatively perceived and linked with the enhancement of a patient's lost sense of control [35,46], and in reinforcing the passive role of individuals in the decision-making process [46,51].Unappreciated comments and information denials made infertile patients conscious of the poor availability of the team to answer to their specific needs [41,51,96].Unrealistic hope nurtured by the health care team is seen as unfruitful, as high expectations are normally shattered after a few attempts without positive conception results [46].
Professionals' lack of awareness of spiritual needs assessment, and the lack of organizational environment conditions to provide spiritual care, have induced lower levels of satisfaction in fertility services [20].The inability to cope with all involved, the clinical and treatment procedures, lead to burden and, consequently, to treatment withdrawals [53].The high rates of burden in this population may therefore reflect the existing gap in the provision of effective holistic care [20].The assessment of spirituality is quite challenging to nurses and midwives.Nevertheless, recently a synthesis of qualitative studies found that patients living with infertility may have spiritual needs [97].So, nurses and midwifes should attend spirituality, using formal tools or informal strategies such as communicational skills [98].Mandatory interventions towards promoting hope and resilience are essential to empower and help infertile individuals in achieving well-being [20].A nurturing care, capable of transcending the physical reality, should be guaranteed, based on the spiritual care nursing principles of a "healing presence, therapeutic use of self, intuitive sense, exploration of the spiritual perspective, patient-centeredness, meaning-centered therapeutic intervention and creation of a spiritual nursing environment" [91].A sensitive approach to care includes respect for values and beliefs regardless of a religious affiliation [20].However, workload [20] and lack of training to deal with a patient's spiritual issues [67] emerge in nursing and midwifery disciplines as barriers in bringing this dimension into practice [30].Nevertheless, efforts have been made to perceive this context of living with infertility as an opportunity to provide spiritual care [20].Advanced education and improved communication skills to adequately assess distress have been reported as emergent in the provision of accurate information to infertile couples and in enhancing empowerment in decision-making regarding fertility treatments [53].
A holistic approach to the care of infertile couples may be effective when a thorough assessment of their physical, emotional, psychological, cultural, social and spiritual needs is implemented and when interventions are taken towards experiences in and beyond the fertility clinic.Nurses and midwives must be prepared, aware, present and supportive in keeping hope, healing, spiritual well-being, psychological adaptation, life satisfaction and a state of well-being [35,81], within a multidisciplinary healthcare team.Equally essential is to be respectful of each human singularity as well as their personal values, religion and beliefs [20], in the context of living with infertility.

Conclusions
Dealing closely with situations of chronic illness and death experiences has awakened a broad interest in health teams in the development of a spiritual approach in care, particularly in caring for vulnerable people.Similarly, the intense life experiences lived by infertile people has deep manifestations in their sense of self and meaning in life, and can also be considered an emergent opportunity for spiritual care.Spirituality should be considered from the beginning to the end of life, and couples express suffering when facing this situation, from the diagnosis of infertility to the treatment and beyond.This dominates the individual's thoughts, feelings and purpose in every aspect of their lives.This unanticipated event, when associated with an inability in transitioning and creating a new meaning in life, may force individuals to a crossroads between the decision to continue the pursuit of having a biological child and the decision to adopt a child.Although the need for a theoretically integrated approach has been recognised in the fertility setting, the biomedical approach still prevails and fragmented attention is still given to the patient, with poor consideration of spirituality.Infertility is not merely the absence of a desired state of parenthood, instead it is a more complex experience with several internal and external dimensions being affected by this reproductive health condition.Hope and resilience are the main issues in fertility healthcare services, however success is not guaranteed.Following interactions with staff are therefore affected and sometimes this results in extreme reactions like withdrawal from treatment.Translation into the development and implementation of specific policies regarding the spiritual approach is needed, as infertility is a growing and wide-ranging health problem.Equally essential is collaborative teamwork and recognition of one's own discipline's limitations in providing counselling and spiritual comfort.An integrated approach, respectful of the boundaries of each discipline's fields of intervention, is the answer to calls for an increased quality in nursing and midwifery care and the promotion of the patient's well-being.
Future research is needed in adapting existing instruments for measuring spiritual well-being, hope, resilience and life satisfaction in this population.Longitudinal and cross-cultural studies should be implemented in order to understand how spiritual needs evolve through diagnosis, treatment and beyond.The impact of this reproductive conditioning is usually addressed in small samples and by gender, which poses the need for a broader understanding of this reality lived by couples and the impact it exerts on a relationship.In addition, broader understanding is required of the effect that religious belief has in a patient's decision-making in engaging in medical treatments for infertility, and how faith in believers and non-believers evolves through all phases of diagnosis, treatment and after ceasing ART.Evidence related to the effectiveness of spiritual interventions in nursing and midwifery are essential to develop a more integrated and holistic approach to care, not only in infertile individuals that pursue ART but in those who experience this reproductive conditioning outside fertility clinics.
In conclusion, it is the responsibility of professionals in the nursing and midwifery disciplines to develop evidence-based knowledge and practices that guarantee a higher quality of care to people who endure the struggle of not having a biological child.