However, as seen in my literature review, there is a need to carry out research using qualitative research which would allow the researcher to provide complex textual descriptions of how people experience a given issue. It provides information about the 'human' side of an issue ' that is, the often contradictory behaviours, beliefs, opinions, emotions, and relationships of individuals (Mack et al., 2011). Qualitative methods are also effective in identifying intangible factors, such as social norms, socioeconomic status, gender roles, ethnicity, and religion, whose role in infertility issue may not be readily apparent (Malahlela, 2012; Mark et al., 2011). Therefore, a qualitative research approach will enable detailed understanding of how couples with infertility make sense of infertility treatment on their relationship and those factors that support or hinder the relationship as a result of infertility diagnosis and treatment.
Furthermore, most studies have focused on the impact of infertility on an individual especially on women or the studies have considered the impact of infertility on women and men separately. Only two studies in Nigeria have focused on couples and how infertility affects the relationship (Orji, Kuti and Fasubaa, 2002 and Audu et al., 2014). Therefore, the current evidence base reveals gaps in approach. Furthermore, it could be argued that without exploring the experiences, context and meaning of poorly understood phenomena, such as the impact of infertility diagnosis and treatment on couples' relationship, future research of poorly understood phenomena cannot be generated with any degree of certainty' (Crabtree and Miller, 1999). Therefore, in order to develop and build upon the current evidence on the impact of infertility diagnosis and subsequent treatment on couples' relationship, it is imperative that we explore and understand the meanings of infertility to couples and understanding is best generated through qualitative design (Silverman, 2013).
3.2 A Qualitative study
This research will adopt a qualitative research to explore how infertility affects couple relationships with regards to infertility diagnosis and subsequent treatment. Qualitative researchers depend on several of the human senses as they collect data regarding what they hear, see, and read from the people and places and events and activities (Rossman and Rallis, 2011). Qualitative research expresses a preference for contextual understanding and is interested in the meanings that an individual attributes to events (Willig, 2013; Crabtree and Miller, 1999). The participant's meanings further suggest multiple perspectives on a topic and diverse views (Creswell, 2013. Pp ). In essence, qualitative research provides an "indepth understanding of some type of social, sensitive phenomena that would not be possible by quantitative research" (Ritchie, 2003). In contrast to quantitative research, which have predominantly been used in studies assessing the impact of infertility (with a focus on causal relationship amplified in terms of verification, predictions and observational statements), qualitative research offer alternate ways of exploring human behaviour (Bryman, 2012. Pp ).
Qualitative research does not typically rely on a single data source, they typically gather multiple forms of data, such as interviews, observation and document. Hence, qualitative research process requires complex reasoning through inductive logic (Maxwell, 2012). This logic involves building up of patterns, categories or themes from the bottom up, by organising the data inductively into increasing abstract units of information (Creswell, 2012 pp; Maxwell, 2012). Inductive process involves, working back and forth between themes until a comprehensive set of themes are formed (Creswell, 2012. pp).
Consequently, it is arguable that a qualitative approach is especially appropriate for this study because many experiences and perceptions related to infertility cannot be quantified (Fledderjohann and Johnson, 2015). It requires instead, a detailed understanding of the meaning of infertility to the affected couples how it affects their relationship. This detail can only be established by talking directly with the affected couples, going to their homes, and allowing them to relate their perceptions unencumbered by what is expected to be found or what has been read in the literature (Peterson et al, 2008). Also, a qualitative research appears to be a suitable approach in describing the meaning of infertility in more detail and expanding understanding on its effect on couple relationships. However, there is not one but many qualitative research methodologies which have a shared concern with context and meaning, many of them are deeply rooted in various theories of knowledge (epistemology). These theories of knowledge make assumptions about how and what we know about the world (Bryman, 2012) and the claims that such knowledge can make on the subject being studied (Creswell, 2013).Therefore, in keeping with a qualitative methodological position, an Epistemological position is integral to qualitative methodology in terms of how we can know/ explore/understand the world (Bryman, 2012).
3.2.1 Qualitative research: An epistemological view
Qualitative researchers can adopt a variety of epistemological positions and there are different ways of conceptualising these epistemological positions assumed by the different approaches to qualitative research (Creswell, 2013 pp). An epistemological consideration is concerned with what kind of knowledge is possible, acceptable, adequate and legitimate in a discipline (Creswell, 2013). Bryman (2012. pp) argues that a particular central issue of what is an acceptable knowledge of a discipline is the question of whether the social world should be studied according to the same principles and procedures as the natural world (Positivism). Although, the study of the social world requires a different logic which is concerned about the distinctiveness of human as opposed to the natural order (Interpretivism).
Interpretivism involves the study of the social world; therefore it requires a different logic of research procedures, one that reflects the distinctiveness of humans as opposed to the natural order (Creswell, 2012). In interpretivism, an individual seeks understanding of the world in which they live and work by developing subjective meanings of their experience which is directed towards certain objects or things (Creswell, 2012). The aim of the research, then, is to rely as much as possible on the participant's view of the situation which is formed through the interaction with others and through historical and cultural norms that operates in individuals lives (Creswell, 2012). This is opposed to the na''ve realist approach, whose belief lies on an objective reality or truth waiting to be discovered (Blaikie, 2007). Rather, the interpretivist believes that we construct reality in our given situations and therefore it follows that knowledge and understanding are highly contextual and situation-dependent; therefore, there is not one but many insights into the same phenomenon (Willig, 2001; Madill, 2000). In practice, the question becomes broad and general so as to enable the participants construct meanings to a situation, a meaning which is typically formed through interaction with other persons (Creswell, 2012).
This section has shown that the interpretivist approach is concerned with the empathic understanding of human action rather than the forces that deemed to act on it. An interpretivist approach to social world enquiry will therefore be applied to this research as it seeks to explore couples understanding of infertility and how it impacts on their relationship.
The next section will look at the ontological philosophical view and how it shapes the research question better. Bryman (2012) argues that questions of social ontology (A belief system that relates to the nature of being, becoming, reality and existence; the nature of what can be known) cannot be divorced from issues concerning the conduct of social research.
3.2.2 Qualitative research: An Ontological view
In ontological study, if knowledge is an object, then it must exist independently of the human mind, whereas if it is only an idea, then it can only exist subjectively in someone's mind (Fleetwood, 2005). Qualitative research approaches open a researcher to different multiple realities with the intent of reporting these realities (Johnson and Onwuegbuzie, 2004). There are two ends of a continuum a researcher can take to understand how a participant in a research views their experience differently; from an objectivism view (positivism) or subjectivism (Constructionist) view (Bryman, 2012).
Objectivism is an ontological position that implies that social entity in question comes across as something external to the actor and as almost tangible reality of its own (Blaikie, 2007; Sarantakos, 2012). It has the characteristics of an object and hence of having an objective reality (Bryman, 2012). Objectivism ontology as a choice leads to positivism epistemology, which is accompanied with a deductive research approach and thus, quantitative research methods would need to be employed (Sarantakos, 2012). Constructionism on the contrary, recognises social phenomenon as created from the perception and consequent actions of those actors concerned with their existence (Silverman, 2003). The selection of constructivism ontology leads to the choice of interpretivist epistemology; therefore, an inductive method will be used within the application of qualitative research methods of data collection and its analysis. Qualitative method of data collection and analysis enables the researcher make an interpretation of the findings of the research, an interpretation shaped by the researchers own experiences and background (Creswell, 2013). The aim of the researcher then is to make sense of the meanings the participants in a research have about the world.
In summary, this research will be viewed from a constructionist point of view because individuals develop subjective meanings of their experiences which are directed towards certain object. The goal of the research then is to rely as much as possible on the participant's interpretations of the situation which are formed through interactions with others.
3.2.3 My epistemological position.
From a personal opinion, the impact of infertility has been a topic with a long standing interest to the researcher. While growing up in a country with diverse cultural and social needs, having a child has been seen to be the essence of all marriages. I have witnessed the impact of infertility has had on my closest aunt. She will now be 50years and still suffering from the challenges from social isolation, deprivation and social pressure which has led to her diagnosis of depression. As a clinical nurse with a public health foundation, talking to couples has emphasised the fact that although intimacy and relationship maintenance is important to them, this does not appear to be an area of high importance for health professionals involved in their care.
As a researcher, I reject the notions of scientific realist standpoint in that I do not believe that there is one single objective reality, independent of our perceptions of it, or that the scientific method is the only true way to access the real world. I do have an affinity to the critical realist approach in that I do believe that there is a real world, but that knowledge of it is influenced by the perceptions of the person in the context of their lives. I identify with many of the assumptions made by the interpretivist epistemological approach as interpretative studies are more useful where understanding and meaning of a phenomenon are the major concern; or where there is insufficient information such as the impact of infertility treatment and diagnosis on couple's relationship.
Therefore, in conclusion, I am advocating a qualitative approach to the study exploring the impact of infertility diagnosis and treatment on the couples' relationship, informed by a constructionist approach. In light of the researcher's epistemological position, this proposal will discuss qualitative research methodologies which are informed by interpretivist epistemologies, such as constructionist versions of Grounded theory and Interpretative Phenomenological Analysis and, in doing so, will provide the justification of why the interpretative phenomenology analysis (IPA) method has been selected.
3.3 Qualitative research methodology.
This section will discuss the constructionist (interpretivism) worldview as it manifest within a grounded theory and interpretative phenomenological analysis.
Social constructionist versions of grounded theory according to Charmaz (2006), lies squarely within the interpretive approach to qualitative research with flexible guidelines but a focus on theory developed that depends on the researchers view. Charmaz (2006) argues that categories and theories do not simply emerge from data but are constructed by the researcher through their interaction with the data. Thus, the role of the researcher is acknowledged as well as what the researcher brings to the research process (Strauss and Corbin, 2014). Consequently, in this instance, the theory reflects only one description of the data but contributes to the interpretivist positions on the nature of knowledge.
Whilst social constructionist versions of Grounded Theory have an affinity with the epistemological stance of the researcher and therefore appeared be `an attractive' methodology for researchers wanting to explore the meaning of infertility on couple relationships with regards to infertility diagnosis and treatment, such an approach was not thought to be suitable for the following reasons outlined below. Its suitability to answer research questions regarding the meaning and nature of experience have been questioned with some advocating the use of phenomenological types of inquiry for this (Smith, 2004; Sin, 2010). It could be argued that, when applied to questions looking to make sense of an experience, as opposed to the unfolding of social processes, the grounded theory method is reduced to a technique for systematic classification (Willig, 2001; Sin, 2010). That means that, studies concerned with capturing the meanings that a particular experience holds for an individual tend to use one-off interviews with participants, transcribe them and code the transcript using the principles of the grounded theory method. The result is a systematic plot of concepts and categories used by the respondents to make sense of their experience (Willig, 2001). While such a plot may provide us with a better understanding of the structure of our participants' experiences, it does not, in fact, constitute a theory (Willig, 2001). Therefore, as the research questions asked in this study are exploring the impact of infertility diagnosis and treatment on couple relationships, Grounded Theory was felt to be an unsuitable research methodology to answer such questions. Moreover, theory generation is not one of the objectives of this study.
Interpretive phenomenology analysis (IPA) has been linked to a constructionist stance (Larkin et al., 2006; Biggerstaff and Thompson, 2008), it is ontologically rooted in critical realism believing that there are unchanging and stable features of reality that exist out with human conceptualisation (Sarantakos, 2012) and that different accounts of phenomena are possible because people experience different components of reality (Smith et al., 2009). There are mainly three theoretical touchstones of IPA, which are; Phenomenology, Hermeneutics and Idiography.
Phenomenology which is concerned with human understanding is originated from the works of Edmund Husserl (1962) who has commonly been deemed to be the, father of phenomenology. His philosophical ideologies gave rise to the descriptive phenomenological approach (Larkin et al., 2006; Husserl 1962). By phenomenology, Husserl meant the study of how people describe things and experience them through their senses. His most basic philosophical assumption was that we can only know what we experience by attending to perceptions and meanings that awaken our conscious awareness (Smith et al., 2009). These experiences are thought to provide essential truths about reality that are difficult to discover through quantitative methodology (Smith et al., 2009).
Phenomenology is both a research method and a philosophical movement, in which the main objective is to explore and describe phenomena as they are consciously experienced (Creswell, 2007). Thus a homogenous group is identified that may vary in size from 3 to 4 individuals to 10 to 15. Phenomenological method does not seek to predict or control behaviour, or to reveal causal relationships, but rather to interpret and understand phenomena by intuiting, analysing, and describing (Creswell, 2007; Moustakas, 1994). It is without theories about causes and as free as possible from unexamined preconceptions and presuppositions (Moustakas, 1994). A phenomenology ends with a descriptive passage that focuses on the essence of the experience for individuals combining what they have experience and how they experienced it (Creswell, 2012).
Husserl (1962) argues that 'the essences' were universal to any lived experience and that they represented the real nature of the phenomenon under investigation, resulting in one correct explanation of the phenomena under investigation. Husserl thought that it was necessary to develop a rigorous, scientific foundation for the natural and human sciences and, as a result, introduced the concept of ''transcendental objectivity'' (Husserl 1962). In order to achieve this, he proposed that individuals had to ''bracket'' the outer world by continually assessing and 'neutralising' any biases and preconceptions that may be present (Lopez and Willis, 2004), only then could contact with the 'essences' be achieved. While Husserl (Phenomenological enquiry) was concerned to find the essence of experience, IPA is more concerned to capture the particular experiences as it is experienced by particular people (Smith et al., 2009). However, IPA ascribes more to the phenomenological works of Heidegger (1962) and Gadamer (1989).
In developing the work of Husserl further, Heidegger (1962) began his philosophical career as a student of Husserl, moved away from the transcendental project and set out the beginning of hermeneutics (theory of interpretation). Hemeneutics is a method of enquiry which is concerned about experience rather than what was consciously known; it focused on the `person and the context of their existence' (Lopez and Willis, 2004). Heideggar believed that phenomenological method of enquiry should be concerned more about the relationship of the individual to their entire life and used the term 'in dissolute unity' to emphasise this concept (Maguire, 2011). Heidegger (1962) in Smith et al. (2009) advocated that there are many ways of `being in the world' but most important was in being aware of `one`s own being' that is to say, Dasein. To exist in this way, he believed, was to exist `authentically' and he proposed that access to the 'lived experience' can only be achieved through exploration of this entity. He questioned Husserl`s phenomenology and believed that narrative devoid of interpretation was impossible and initiated interpretation as both a concept and method of phenomenology (Maguire, 2011). Heidegger (1962) in Smith et al (2009) believed that understanding through interpretation was meaningful and resulted in the true revelation of the phenomena.
Furthermore, in contrast to the works of Husserl (1962) and his views on 'bracketing', Heidegger (1962) in Smith et al (2009) believed the presence of fore-structures such as existing knowledge and experience to be both useful and valuable. He used the term 'the hermeneutic circle' to illustrate the continual relationship between pre-existing knowledge and experience in understanding.
Another writer on hermeneutics is Gadamer (1989) in Smith et al (2009) who moved on from the work of Heidegger, by questioning how understanding was possible. He agrees with the work of Heidegger that language and understanding were inseparable features of `being in the world' (Smith et al., 2009). However, he tends to emphasise on the importance of history and the effect of tradition on the interpretative process (Smith et al., 2009). Gadamer (1989) in Smith et al (2009) also argues on the notion of bracketing was `absurd' because being aware of one`s own experience enables individuals to transcend to a `fusion of horizons' (Gadamer, 1989in Smith et al ). By horizon, Gadamer means `a range of visions that includes everything that can be seen from a particular vantage point', thereby fusion of horizon means a dialectical interaction between the expectation of the interpreter and the meaning of the text (Laverty, 2008). From this viewpoint, a research grounded in the works of Gadamer aims to understand the fusion of horizons between the researcher and the participant (Laverty, 2008).
Therefore, Heidegger`s (1962) viewpoint on the individual `being in the world' and Gadamer (1989) view on the importance of history and tradition in shaping our perception of the world, supports IPA`s focus on seeking knowledge from the participant perspective and interpretation as it acknowledges the researchers past and personal beliefs in the construction of knowledge (Smith et al., 2009; Laverty, 2008). IPA also acknowledges how access to the participants `lived experience' is influenced by their role in the research process in that they are required to make sense of participants accounts through a process of interpretation (Smith et al., 2009). IPA is said to involve a double hermeneutic in that as well as the individual attempting to make sense of their world, the researcher is, in turn, trying to make sense and interpret the accounts of the participant (Eatough and Smith 2006).
Eatough and Smith (2006) describe IPA as an idiographic mode (a mode of understanding the meaning of a unique and subjective entity) of inquiry which is in contrast with the nomothetic approaches (mode of deriving law that explain objective phenomenon in general) where analysis is conducted only at a group level. IPA advocates the examination of both individual case and analysis from a group level. Individual case can enable claims from an individual basis and from a group level, it enables the identity of shared themes that participant may have (Smith et al., 2009; Eatough and Smith, 2006).
Therefore, following a discussion on the philosophical view point of IPA, a rationale for why IPA was selected to study the impact of infertility diagnosis and subsequent treatment on couples' relationship were provided in the following text.
3.3.1 Rationale for IPA
One of the main differences between other qualitative approaches such as grounded theory to IPA is the role of cognitions. IPAs focus on the role of cognitions and how these can be inferred through the analysis of language, which allows the researcher to explore how individuals make sense of their experiences and what they think of its impact on their lives (Smith et al. 2009; Smith and Eatough 2007). In order to explore and understand the impact of infertility on the couples' relationship it is important that we get some insight on the how the participants feel and think about this phenomenon and the meanings that they ascribe to it; from the participant perspective. As advocated by Creswell (2013), we need to explore the meanings that particular phenomenon have to the person experiencing it. IPA will enable the researcher to facilitate such an exploration (Smith et al. 2009).
The phenomenological origins of IPA and its focus on the lived experience of the person in the context of their own life (Smith et al. 2009) has an affinity with the constructionist standpoint of the researcher and the importance of gaining knowledge in the context of the person being in the world. The hermeneutic component of IPA (Lopez and Willis, 2004; Laverty, 2008) also identifies with this constructionist stance in viewing knowledge as a co-construction with the researcher and the participant. This is in contrast to other methodologies which aim to minimise the role of the researcher in the process.
Finally, the idiographic (It suggests that everyone is unique and therefore everyone should be studied in an individual way) focus of IPA (Smith et al. 2009) is in contrast to the predominate nomothetic approach (focus on objective knowledge through scientific methods to produce statistically significant results) to the study of impact of infertility, which will facilitate an in-depth exploration of this phenomenon from the perspective of the individual, thereby, understanding the impact on couples' relationship. Therefore, in conclusion, having provided justification for the qualitative exploration of impact of infertility diagnosis and treatment on couples' relationship and why IPA was considered an appropriate methodology, the methods used in this study will now be presented.