This qualitative study was undertaken using an interpretivist/constructivist paradigm and a constant comparison/grounded theory design [27] [28] with semi-structured, in- depth open interviews to explore the impact of subfertility and fertility treatment for parents who successfully achieve pregnancy following fertility treatment. The COREQ checklist [29] was used to ensure that our study complied with the criteria for qualitative research. We intended to interview until we reached saturation of concepts.

The participants―who have conceived and given birth as a result of fertility treatment- were recruited via an announcement on an internet forum for people with fertility problems and via snow-ball sampling. Nine interviews with eleven participants were held. Two couples were interviewed at home in Groningen in the spring of 2011 by final year midwifery students (student group A) who had received a five-day training on interviewing and qualitative research. After the decision to continue this study, seven interviews with participants outside Groningen were held by phone by CW (psychologist) in November 2011. All interviewees had gone through a period of subfertility and finally became pregnant after fertility treatment. The interviewers did not know the interviewees. There were two other persons interested in participating in the study, but they dropped out for unknown reasons before the interviews were held.

Prior to data collection, the topic list and semi-structured interviewing method were tested in a pilot interview with a midwife lecturer. The topic list shown in Table 1 was used to ensure internal consistency of the interviews. The follow-up questions depended on what the interviewees said. All interviews were recorded on tape, and lasted 55 minutes on average (range: 28 - 91 minutes). Participants were encouraged to speak freely about their experiences before, during and after pregnancy in a single interview. The interviewers stressed their neutrality by exploring both positive and negative remarks of participants. At the conclusion of each interview the participants were invited to provide feedback on the interview and to verify a short oral summary. Directly after

an interview the interviewers evaluated their findings and formulated areas that called for more in-depth exploration in the next interview related with the current study, following the constant comparison/grounded theory design.

All nine interview recordings were transcribed verbatim. The transcripts were initially read separately by JM, NM and CW and text segments were selected on relevance to the research question. Data were then categorized into themes by each researcher, using content analysis [27] . The interviews were first open coded (labelling), axial coded (categorized) and then selectively coded (thematically). The analyses were performed by CW (psychologist), JM and NM (student midwives), with consensus reached on the findings and with reflections on the research process and the role of the researchers. Transcripts were coded by each researcher independently, and the code trees generated were in agreement with each other. Examples of the analytical coding process are shown in Table 2. All codes, categories and themes found were then arranged in a code tree (Figure 1). The analysis indicated data saturation, which means that the inclusion of further data would probably not have resulted in the identification of new themes. Quotes were translated into English by an accredited translator. To assess the credibility of our findings, the final subthemes and main themes were discussed in a group session of health care professionals at a conference, with midwifery lecturers and with a midwifery consultant at a fertility centre.

This study was approved for research purposes by the scientific committee of our institute (WC2011-005) and supported by patient organisation Freya. All interviewees received written information by email and verbal information about aim and content of the interviews, and the interviewees gave verbal informed consent to audio taped interviews. All participants were assured of anonymity and confidentiality and that they could freely withdraw from the study at any time. All data were anonymized. Each participant was given the opportunity to read their transcript and a draft version of this article. No further comments were returned.

Fertility treatment for our participants was associated with a range of negative emotions, which is consistent with earlier literature [6] [23] [30] [31] [32] . In addition our

participants described positive emotions that could occur, especially hope. It seems that particularly the alternation of hope with disappointment and stress is what makes the fertility treatments so emotionally taxing. The women involved also lose much of their self-confidence, and feel that they can no longer trust their own body. Couples and women were exposed to a whole range of emotions during the subfertile period, and these feelings were even felt after successful fertility treatment. The feelings and emotions which played a role during the subfertile period and fertility treatment might be only incompletely resolved and thus persist for many years, even after pregnancy.

Our analysis showed that the women we interviewed regarded motherhood as a kind of basic instinct and they could not imagine life without children. This may be one of the reasons why none of our interviewees decided to stop their treatments. This influence of the idea of motherhood on the perception of subfertility concur with the review by Greil et al. [33] . On the other hand, if they had stopped treatment, they could not have been in our study anyway.

Like ESHRE [23] , Wilkes et al. [34] and Martins et al. [35] , our study shows that understanding, support and the willingness to listen can have an important impact on the mental well-being of subfertile people. We found in our study that participants have difficulty dealing with the spontaneous pregnancy of their friends; friends who then advance into a new phase of life associated with pregnancy and childbirth. In fact, both the subfertile woman and her pregnant friend may find it difficult to respond positively to this situation. Unlike Wilkes et al. [34] , however, we did not find that this seriously impaired the friendships.

One woman from our study consulted a medical psychologist and found this very helpful. Boivin, et al. [30] and Péloquin [8] confirmed that talks with a psychologist help to reduce stress. The role of peer-support through internet forums is fairly new to the literature and can reflect the emerging role of internet in health-related behaviours. Particularly the contact with peers who are further in the treatment process may be very helpful and health professionals can provide information about online psychosocial care options, such as contact details of online support groups, or infertility counselling, or psychotherapy [23] . Our interviewees stated that they got a lot of recognition and understanding from people in the same situation on internet forums, and that they appreciated this. However, the cultural context where the study was conducted and the infertility history of the participants need to be taken into account, when interpreting their openness in sharing the infertility experience with peers and relatives.

Similar to the findings of Wirtberg et al. [6] and Wilkes et al. [34] , our study underlined the importance of a good relationship with the partner. Our findings stress the powerlessness of the man as a source of tension. Maintaining communication and giving one another leeway to express the same emotions in different ways were recurrent topics in the interviews. Wilkes et al. [34] and Klock [36] also found that couples were stronger and could cope with stressful situations better if they were united. We found that the partners did their best to be there at every treatment session, and to understand what was going on. Like Schmidt, et al. [9] , our study revealed that joint attendance at treatment sessions sometimes improved the relationship between the members of a couple because they got to know one another better and built up a real team spirit.

One of the strengths of this study is its originality. To the best of our knowledge, this study is the first to explore the clients’ perception of subfertility following successful assisted conception in the Netherlands, where a MAC pregnancy can be monitored by midwives in primary care. We believe that the interpretative/constructivist paradigm as frame of reference is appropriate to our research question. Our study explored the subjective perception of subfertility following assisted conception. We let the parents who have conceived and give birth as a result of fertility treatment speak about delicate issues. To increase the credibility of our findings, we used diverse researchers (investigator-triangulation), a varied group of participants (negative case analysis) and we conducted both individual interviews and interviews with couples letting these two methods complement each other. Particularly delicate topics might be more readily discussed in individual interviews covering maximum depth, whereas for other topics this might be the case in an interview with couples, where there is a more dynamic interaction between the couple and this can generate new ideas or evoke new insights that might not have come up in a one on one interview (data-triangulation). We maintained an audit trail in which we indicate with whom we had a conversation and about what or whether there were any special circumstances. The final subthemes and main themes were discussed in a group session of health care professionals at a conference, and with a midwifery consultant at a fertility centre and with midwifery lecturers (peer debriefing). Participants checked intermittent results of the study (member-checking). Transferability was established through “thick description” [27] , in which detailed description of data with a rich mix of participants’ quotations were considered. To round off the study, we used the COREQ checklist [29] to ensure that it complied with the criteria for qualitative research.

Despite these strengths, limitations need to be taken into account. The main limitation involves the small sample in which particularly men’s perceptions could not be investigated fully. The small number of the joint couple interviews might restrict the impact of the study for the research field. Nevertheless, usable results were obtained that were in agreement with the findings of other authors. Another limitation might be that participants had undergone a wide range of fertility treatments, with no acknowledgements that more invasive forms of treatment or the number of treatment cycles, may have affected the perception of the psychosocial aspect of subfertility. In addition, there are disadvantages related to the use of telephone interviews. However, given the wide variety of perceptions captured, we believe that this had no significant influence on the results of this study. Memory biases may have affected the research findings, due to the retrospective nature of the study and the positive pregnancy outcome reached by the participants. The recruitment strategies (through internet forums and snowball sampling) may have also influenced the findings, reaching participants who may be more motivated/comfort Table to share their subfertility experiences. Our study may not add many new insights to what is already known, since there is a considerable body of evidence relating to the psychosocial aspect of childbearing after MAC [23] . Nevertheless, we can focus on how this combined evidence can be translated into tangible messages for midwives and other maternity care providers in community, who might consider pregnancy after MAC as a “normal” pregnancy with no indication for increased risk or extra attention.

Like Gameiro, et al. [37] our study describes psychosocial needs clients experience across their fertility treatment pathway, such as emotional needs (well-being, e.g. anxiety, depression, quality of life) and relational needs (relationship with partner if there is one, family friends and larger network). We did not ask for or found specific behavioural needs (lifestyle, exercise, nutrition and compliance) or cognitive needs (treatment concerns and knowledge).

Subfertility and fertility treatment are intensive life events that are associated with many different feelings and emotions. It is advisable to take this into account during the antenatal and postnatal care of women who have undergone fertility treatment, and to devote extra time to their emotional well-being during pregnancy and the immediate postnatal period. the theme Emotions during MAC highlight that participants experienced negative emotions but also strong emotional shifts (with positive emotions) at different stages of the subfertility period and a sense of uncontrollability toward the future. As such, primary care midwives may need to provide psycho-education to clients during preconception counselling, about the emotional experience at different stages of the subfertility period, promote realistic expectations toward subfertility treatments and discuss strategies that can help clients to deal with the sense of uncontrollability toward the future. The specificities of each client (namely, the meanings attributed to parenthood) need to be taken into account in clinical practice, because it could influence the subjective experience of subfertility.

Given the importance of social support to our participants, we recommend that midwives and other maternity care providers should check thoroughly whether their clients received sufficient social support during fertility treatment, and whether they are still receiving such support during and after pregnancy. If necessary, the maternity care provider could suggest that clients visit relevant internet forums. Fertility treatment can have various effects on the woman’s relationship with her partner and our participants emphasized the involvement of the partner in the treatment. It is therefore advisable for the midwife or maternity care provider to also involve the partner in prenatal checks. Couple communication, emotion sharing and shared decision-making can facilitate the psychosocial adjustment of the couples to subfertility period and may be enhanced by healthcare providers. Further prospective research could be aimed at investigating the male experience of subfertility or conducting other joint couple interviews in order to provide an in-depth analysis of couple dynamics/processes and gender issues related to the subfertility period.