Fertility-related distress and female identity reconstruction among reproductive-age women with breast cancer in China: a qualitative study

Fertility-related distress and female identity reconstruction among reproductive-age women with breast cancer in China: a qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Fertility-related distress and female identity reconstruction among reproductive-age women with breast cancer in China: a qualitative study Jun Guo, Jinnan Gao, Xiaojun Zhang, Yan Gao, Hulin Liu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9443174/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 21 You are reading this latest preprint version Abstract Background Breast cancer is common among reproductive-age women in China. Treatment may impair fertility and cause fertility-related distress, which is closely associated with female identity. However, in-depth qualitative studies remain scarce. Aim To explore the experiences of fertility-related distress, its relationship with female identity changes, coping dilemmas, and pathways of identity reconstruction among reproductive-age women with breast cancer in China. Methods A qualitative study based on interpretative phenomenology and self-identity theory was conducted. Semi-structured in-depth interviews were performed with 25 participants. Data were analyzed using Graneheim and Lundman’s qualitative content analysis. Results Four themes were identified: (1) multidimensional fertility-related distress; (2) a vicious cycle between distress and negative identity changes; (3) multifaceted coping dilemmas; and (4) a progressive pathway of identity reconstruction including expectation adjustment, self-value remodeling, post-traumatic growth, and multidisciplinary support. Conclusion Fertility-related distress is culturally specific and closely tied to female identity, forming a vicious circle. A multidisciplinary support model is needed to alleviate distress and promote identity reconstruction to improve quality of life. Breast cancer Fertility distress Female identity Identity reconstruction Reproductive-age women Qualitative study Figures Figure 1 Introduction According to the 2022 Global Cancer Statistics (GLOBOCAN 2022), there were 2.3 million new breast cancer cases, accounting for 11.6% of all new cancer cases worldwide, ranking second among all cancers and first among female malignancies[ 1 ]. In China, breast cancer affects patients at a relatively young age, with a median age at diagnosis of 45–49 years, approximately 10 years earlier than that in Western countries. Young patients account for a considerable proportion: those aged 35 years and below represent more than 10% of all breast cancer patients, while extremely young patients aged 25 years and below account for about 0.5%[ 2 ]. Young breast cancer patients often undertake key roles in their families and society and have high expectations for their quality of life[ 3 ]. With advances in diagnosis and treatment, the cure rate of breast cancer has improved. Although conventional treatments such as chemotherapy, radiotherapy, and endocrine therapy can effectively control the disease and improve survival, they inevitably impair ovarian function, leading to a growing number of women of childbearing age with breast cancer facing the risk of impaired or even permanent loss of fertility[ 4 ]. For women, fertility is far more than a mere physiological reproductive function; it is also an important carrier for constructing self-identity, fulfilling family roles, and realizing social values, and is closely associated with women’s self-perception, family status, and social evaluation[ 5 ]. Fertility-related distress caused by impaired fertility is not a single emotional response, but a complex psychological experience involving multiple negative emotions such as anxiety, depression, grief, and self-denial. Studies have shown that such psychological distress not only directly impairs patients’ treatment compliance and reduces therapeutic efficacy, but also exerts long-term adverse effects on their psychological status, significantly lowers their long-term postoperative quality of life, and even triggers a series of family conflicts and social maladjustment problems[ 6 ]. At present, some progress has been made in international and domestic research on fertility‑related issues among women of childbearing age with breast cancer. However, most studies have focused on the development and application of fertility preservation technologies and quantitative surveys of fertility intention, using quantitative research designs such as cross‑sectional studies and cohort studies that emphasize the distribution and correlations of relevant indicators[ 7 ]. In-depth exploration of fertility-related distress in this population, as well as qualitative investigations into the identity changes and psychological mechanisms underlying such distress, remains insufficient. Notably, most existing research has been conducted within Western cultural contexts, neglecting the impact of China’s unique cultural and social environment on the psychological well‑being of women of childbearing age with breast cancer[ 8 ]. In traditional Chinese family values, continuing the family line and childbearing are often regarded as core responsibilities and key manifestations of women’s value. Coupled with widespread societal expectations of women’s maternal role in modern society, Chinese women with breast cancer of reproductive age not only endure trauma caused by the disease itself but also face multiple pressures from family and society when confronted with impaired fertility. This results in more complex psychological conflicts and identity confusion, and the manifestations and influencing factors of their fertility‑related distress show distinct local characteristics[ 9 ]. Although several domestic studies have examined fertility concerns among young breast cancer patients, most are quantitative surveys that fail to deeply explore the mechanisms of identity change underlying such distress[ 10 ]. Therefore, an obvious research gap exists regarding in‑depth qualitative studies on fertility‑related distress and identity reconstruction among women of childbearing age with breast cancer under the Chinese cultural context. Methods Design This study adopted an interpretative phenomenological design as a qualitative research approach, with interpretative phenomenology as the core theoretical framework[ 11 ], and integrated Erikson’s theory of identity formation to establish the research structure[ 12 ]. It focused on the lived experiences of fertility-related distress and changes in female identity among Chinese women of childbearing age with breast cancer, and further explored their subjective feelings, underlying psychological mechanisms, and pathways of identity reconstruction. Participants and recruitment This study was conducted in China.Inclusion criteria:Women of childbearing age aged 18–49 years;Confirmed diagnosis of breast cancer by pathological examination;Clear consciousness, able to communicate fluently in Mandarin Chinese with basic verbal expression skills;Voluntary participation in the study, signed informed consent, and willingness to complete semi-structured interviews and subsequent data collection.Exclusion criteria:Patients with other malignant tumors as the primary diagnosis (breast cancer as secondary disease);Comorbid severe mental illness or cognitive impairment that prevents participation in interviews;Severe complications such as severe hepatic or renal insufficiency, cardiovascular or cerebrovascular diseases that hinder normal study participation;Individuals who refuse to Participants were recruited via referrals from medical staff in the Breast Surgery Department and advertisements posted on the official WeChat public account of the Breast Surgery Department, a formal science popularization platform approved by the hospital’s ethics committee focusing on female reproductive health and cancer survivorship education with certain authority and influence. A total of 27 women expressed interest in participating in the study: 22 responded to the advertisements on the WeChat public account, and 5 were recruited through staff referrals. They received written study information and were screened with relevant questions to confirm eligibility. Finally, 25 women met the inclusion criteria and were enrolled in the study. provide informed consent or withdraw from the study midway. Twenty participants were interviewed via Tencent Meeting video, three via telephone, and two through face-to-face interviews. All interviews were conducted by the researcher between October 15, 2025, and January 25, 2026. Interviews were audio-recorded and lasted 30–60 minutes, with a median duration of 45 minutes. All participants provided written informed consent prior to participation. Interview recordings, transcribed texts, and related research data were collected with the explicit consent of participants. Personal privacy information including names, exact age, contact details, and medical records was anonymized (coded as G1 to G25) to protect participant confidentiality, and the entire study was conducted in strict accordance with medical ethical principles. A semi-structured interview guide was developed specifically for this study according to the research purpose and relevant literature. The interview guide included four core sections: experiences of breast cancer and treatment, fertility-related distress, changes in female identity, coping dilemmas, and pathways of identity reconstruction. The full English version of the interview guide is provided as Supplementary Material 1. Data analysis Data analysis was performed using qualitative content analysis as proposed by Graneheim and Lundman[ 13 ], focusing on identifying similarities and differences in participants’ experiences regarding fertility-related distress and changes in female identity. First, the researcher repeatedly read all interview transcripts and field notes to fully grasp the overall context and core meaning of the data and gain an in-depth understanding of participants’ subjective experiences. Based on this, meaning units relevant to the research topic were identified and extracted, condensed to capture their core significance, and assigned corresponding codes. All codes were then compared, categorized, and grouped into distinct categories. Examples of the coding and category development process are presented in Table 1 . Table 1 Example of the formation process of meaning units, codes and categories Meaning unit Condensed meaning unit Code Category "After being diagnosed with breast cancer, I kept worrying that the treatment would leave me unable to have children. I also feared the cancer might be hereditary and passed on to my child. The doctor did not explain in detail how to avoid these risks, and the more I thought about it, the more anxious I became." After diagnosis, patients experienced significant anxiety due to concerns about loss of fertility and hereditary cancer risk, compounded by insufficient relevant information. Concerns about fertility; Anxiety over hereditary risk;Anxiety caused by insufficient information Multidimensional profiles of fertility-related distress "I have always believed that a woman's value lies in having children and being a mother. Now, because of this treatment, I may not be able to give birth. I feel less like a complete woman, and the more I think about it, the more inferior I feel, making it even harder to accept the reality of my illness." Fertility-related distress leads to negative changes in self-identity and a sense of identity disruption, which in turn exacerbate the distress, forming a vicious cycle. Sense of identity disruption; Negative changes in self-identity;Exacerbated distress Fertility-related distress and changes in female identity interact with each other. "I want to preserve my fertility, but I fear it will interfere with cancer treatment. My family wants me to focus on treatment first, yet I do not want to give up the chance of becoming a mother. I cannot express myself clearly when talking to my doctors, and I feel extremely conflicted." They face value conflicts between survival and fertility, uncertainty regarding the risks of fertility preservation, contradictions between family expectations and personal wishes, as well as inadequate doctor-patient communication. ·Conflict between survival and fertility;Concerns about risks of fertility preservation Inadequate doctor-patient communication Coping dilemmas "I gradually adjusted my mindset and stopped regarding childbearing as the only value of being a woman. I took the initiative to consult psychologists and multidisciplinary teams, learned to accept myself, and found my own meaning in life." Through expectation adjustment, self-worth reconstruction, and active pursuit of multidisciplinary support, post-traumatic growth is achieved, and the reconstruction of female identity is completed. Expectation adjustment Self-worth reconstruction Multidisciplinary support Post-traumatic growth Pathway of identity reconstruction Data analysis was conducted jointly by the first author (JG) and a co-researcher (HL). The two researchers independently read and coded five interview transcripts, after which they held detailed discussions to compare coding results, verify coding logic and category assignments one by one, and reach a consensus. The remaining transcripts were then coded by the lead researcher. Manifest content (information directly and explicitly expressed in the text) was presented descriptively in the form of categories[ 14 ]; latent content (deep underlying meanings, emotions, and psychological mechanisms implied in the text) was interpreted at an explanatory level in the form of themes, focusing on the intrinsic relationship between fertility-related distress and changes in female identity. The prior perceptions of the first author (JG) were grounded in clinical experience and research accumulated as a medical professional and researcher in the field of psychological intervention for women of childbearing age with breast cancer. Over the years, as a clinical practitioner, the researcher has encountered and assisted numerous young breast cancer patients in addressing fertility-related distress and identity confusion. Such prior understanding facilitates the detection of subtle emotional and cognitive differences in participants’ narratives. Meanwhile, the researcher explicitly acknowledged personal values and preconceptions to avoid subjective bias in the analytical process[ 15 ]. The co-researcher (HL) possessed clinical and research expertise in psychological nursing and cancer survivorship, offering diverse interpretative perspectives for data analysis and effectively compensating for the limitations of a single viewpoint. Throughout the analysis process, the researcher and co-researcher engaged in continuous joint discussion and reflexivity, repeatedly verifying the rationality of codes, categories, and themes and revising analytical biases accordingly. Two experts in qualitative research were also invited to review the analytical findings, and the coding and theme development were further refined based on expert feedback to enhance the rigor and trustworthiness of the study. Results Participants were recruited from different regions of China and varied in the duration of their breast cancer illness. Their ages ranged from 19 to 48 years, with a median age of 36 years. The time from breast cancer diagnosis to study enrollment ranged from 6 months to 5 years, with a median interval of 2 years. All participants were pathologically diagnosed with breast cancer, including 20 cases of invasive ductal carcinoma and 5 cases of other pathological types. During the interviews, 3 participants reported comorbid mild anxiety or depression in addition to their primary breast cancer diagnosis. Although the interviews focused on participants’ lived experiences of fertility-related distress and changes in female identity, their narratives reflected complex life circumstances, indicating that other coexisting psychological or physical conditions may be intertwined with their overall experiences. Among the participants, 8 had 1 to 2 children and 17 had no children. Seventeen participants held a higher education qualification. Detailed demographic and clinical characteristics of the participants are presented in Table 2 . Table 2 Basic demographic and clinical characteristics of the research objects Characteristics Participants(n = 25) Age (years) 19–30 7cases (28.0%) 31–40 11cases (44.0%) 41–48 7cases (28.0%) Time from diagnosis to enrollment (years) 0.5-2 13cases (52.0%) 2.1-5 12cases (48.0%) Pathological type Invasive ductal carcinoma 20cases (80.0%) Others 5cases (20.0%) Comorbid emotional problems None 22cases (88.0%) Mild anxiety / depression 3cases (12.0%) Number of children Childless 17cases (68.0%) 1–2 children 8cases (32.0%) Educational level Higher education (college diploma or above) 17cases (68.0%) Senior high school or below 8cases (32.0%) Four core themes were identified through data analysis: multidimensional manifestations of fertility-related distress, reciprocal influences between fertility-related distress and changes in female identity, dilemmas in coping, and pathways of identity reconstruction. These themes reflected the deep latent meanings in participants’narratives: complex negative emotions and psychological experiences resulting from impaired fertility; a vicious cycle between fertility-related distress and female identity; dilemmas amid multiple conflicts between fertility and survival, personal wishes and family expectations; and the post-traumatic process of seeking self-acceptance, reshaping identity, and exploring life meaning. Each theme comprised several categories, as detailed in Table 3 . Table 3 Themes and categories extracted from data analysis Theme Categories Multidimensional manifestations of fertility-related distress Sense of identity fragmentation Anxiety over time conflicts between treatment and fertility Concerns about genetic risks Anxiety due to information scarcity The reciprocal relationship between fertility-related distress and changes in female identity Negative changes in self-identity Identity confusion Coping dilemmas Value conflict between survival and fertility Uncertainty regarding the benefits and risks of fertility preservation Conflict between family expectations and personal wishes Inadequate doctor-patient communication Significant differences exist in the level of support from family and partners Pathway of identity reconstruction Expectation adjustment Self-worth reconstruction Redefining female identity Post-traumatic Growth and the Reconstruction of Life Meaning Take the initiative to seek multidisciplinary support Theme 1 Multidimensional Manifestations of Fertility-Related Distress 1)Identity fragmentation caused by loss of fertility (n=25, including 16 nulliparous women and 9 parous women who had not completed their fertility plans): This represented the core distress among all participants who had not fulfilled their fertility intentions, characterized by intense self-denial, regret, and feelings of incompleteness. Strongly influenced by traditional Chinese values emphasizing maternal priority and carrying on the family line, participants universally regarded fertility as a central marker of female identity. “ I have always believed that a woman ought to have a child in her lifetime; it is only natural. Now my doctor says it will be very difficult for me to conceive after treatment. I feel like I am incomplete, deprived of the most basic female function. I dare not join in when friends around me talk about pregnancy. ” (G3, 28 years old, unmarried, nulliparous) Such identity fragmentation essentially reflects an undermined construction of female identity and shaken self-awareness, representing the initial manifestation of an identity crisis . 2)Severe anxiety caused by time conflicts between treatment and fertility (n=22, including 8 undergoing treatment and 14 post-treatment): Women of childbearing age have a limited reproductive window, whereas breast cancer treatment requires a prolonged course and often impairs ovarian function, leaving participants caught in a distressing dilemma between lifesaving treatment and preserving fertility. “ I am 30 years old and originally planned to get pregnant next year. Now I am undergoing chemotherapy every day, and my doctor says I must wait at least 2 years after treatment before considering pregnancy. I am truly terrified that I will never be able to conceive. This anxiety torments me every day and often keeps me awake at night. ” (G7, 30 years old, married, nulliparous, undergoing treatment) Such anxiety stems from attachment to reproductive opportunities and fear of losing fertility hope, further exacerbating disturbances in self-perception. 3) Persistent concern about hereditary risk in offspring (n=18, including 7 with a family history of breast cancer): Participants commonly feared passing cancer on to their children, leaving them in the conflict of “wanting to conceive but daring not to.” “ My mother is a breast cancer patient, and my doctor said breast cancer can be hereditary. I am terrified that my child might develop this disease if I get pregnant, yet I desperately want a child of my own. This contradiction causes me great distress every day. ” (G5, 32 years old, married, nulliparous , with a maternal history of breast cancer) Such concern reflects maternal instinct and also reveals participants’ doubt about their self-worth, as they worry about being unable to provide a healthy future for their offspring. 4) Confusion and anxiety caused by insufficient fertility-related information (n=20): Participants experienced confusion and helplessness due to a lack of professional guidance on fertility preservation and post-treatment reproductive recovery. One participant stated: “ After diagnosis, my doctor only told me to focus on treatment and never mentioned fertility preservation. I later heard from other patients that egg freezing was an option before chemotherapy, but I had already started treatment and it was too late. I do not know where to obtain reliable information, and I feel anxious every day. ” (G1, 25 years old, unmarried, childless, undergoing treatment) The lack of information prevented participants from making reasonable judgments about their fertility prospects and exacerbated their distress. These multidimensional experiences of fertility-related distress are deeply intertwined with patients’ family and cultural perceptions as well as personal fertility expectations. This aligns with the core idea of interpretative phenomenology that “experience and meaning are co-constructed” and also corroborates the essence of identity theory: as a vital component of female self-identity, the loss of fertility directly disrupts an individual’s original self-concept system, leading to self-denial and self-doubt, laying the groundwork for subsequent identity crises. Theme 2 Interactive Mechanism Between Fertility-Related Distress and Changes in Female Identity In‑depth analysis of interview data revealed that fertility‑related distress and changes in female identity did not exert a unidirectional influence, but rather interacted dynamically and formed a vicious cycle. This mechanism was observed among all 25 participants. Supported by interview excerpts and theoretical interpretation, the specific mechanism is described as follows: Impaired fertility serves as the initial trigger for this cycle. When participants learned that their fertility was compromised or lost, they developed the aforementioned multidimensional fertility-related distress. Such distress directly disrupted their original perception of female identity, leading to negative changes in female identity, mainly manifested as feelings of identity fragmentation, unclear role positioning, and negation of self-worth. In turn, these negative changes in female identity further intensified fertility-related distress, forming a vicious cycle: “fertility impairment → fertility-related distress → negative changes in self-identity → identity confusion → further exacerbated distress” (Figure 1). “I used to be very confident and thought I would get pregnant and have a baby smoothly. But when my doctor said it would be very difficult for me to conceive after chemotherapy, I broke down completely and felt I was no longer a complete woman (identity fragmentation caused by fertility-related distress). This thought made me increasingly inferior and unwilling to interact with others. I cannot help crying whenever fertility comes to mind, which in turn makes me more afraid of treatment and worries that further negative changes in my identity will worsen my distress.”(G8, 31 years old, married, childless, undergoing treatment) Theme 3 Dilemmas in Coping with Fertility-Related Distress and Identity Changes All 25 participants encountered varying degrees of dilemmas when coping with fertility-related distress and shifts in female identity. These dilemmas were intertwined and further hindered distress relief and identity reconstruction. Based on interview examples, they can be divided into five subthemes: 1) Value conflict between survival needs and fertility desires:All participants faced the dilemma of prioritizing life‑saving treatment versus preserving fertility, which intensified their psychological distress. “I want to preserve my fertility, especially since I am not married and have no children. However, my doctor insists that I must start chemotherapy immediately, which will result in permanent infertility. On one side is my life, and on the other is my wish to have children. I truly do not know how to choose and struggle with this decision every day.”(G4, 29 years old, unmarried, childless, undergoing treatment) 2) Uncertainty regarding the benefits and risks of fertility preservation:Fourteen childless participants aged ≤35 years experienced decision-making dilemmas due to concerns about the success rate, cost, and future feasibility of egg or embryo cryopreservation .“I wanted to undergo egg freezing before chemotherapy, but my doctor said the success rate is not 100% and the cost is high. My family is not well-off, and even if egg freezing is successful, I am unsure whether my body will be suitable for pregnancy after treatment. Such uncertainty makes me very hesitant.”(G6, 27 years old, unmarried, childless, undergoing treatment) 3) Conflict between family expectations and personal wishes:Twenty-one married participants experienced heavy family pressure, as fertility expectations from family members (especially older generations) clashed with their impaired fertility and reduced reproductive motivation .“My parents-in-law had always hoped we would have a child. After they learned that I might be unable to conceive, I could clearly sense their disappointment. My mother also kept telling me that a woman must have children. Yet my physical condition does not allow it. This internal conflict leaves me feeling deeply depressed.”(G9, 33 years old, married, childless, 3 months post-treatment) 4) Insufficient physician-patient communication and lack of tailored guidance:Nineteen participants reported that clinicians focused primarily on disease management while neglecting their fertility-related needs and failing to provide professional counseling, which aggravated their confusion and distress .“During every chemotherapy visit, doctors only cared about my disease progress and never asked about my fertility-related concerns. I also felt embarrassed to bring it up on my own initiative. I badly needed professional guidance but could not receive any, leaving me confused every day.”(G2, 26 years old, unmarried, childless, undergoing treatment) 5) Significant disparities in family and partner support:Seventeen participants felt lonely and helpless due to insufficient emotional support, as their partners and family members failed to understand their distress and identity confusion .“My husband supports me on the surface but cannot truly comprehend my pain. He often says ‘it doesn’t matter whether we have children or not’. He does not understand what infertility means to me. When I try to confide in him, he always thinks I am being oversensitive. This lack of understanding makes me feel extremely lonely.”(G10, 31 years old, married, childless, undergoing treatment) These dilemmas stem from conflicting meaning constructions among participants regarding “the meaning of survival”, “the meaning of fertility”, and “the value of womanhood”. This not only corroborates the view of interpretative phenomenology that “experience is shaped by context and interpersonal relationships”, but also aligns with the core tenet of identity theory: the construction and reconstruction of individual identity require the synergy of external support (family, medical staff) and internal cognitive adjustment. When external support is inadequate and internal cognition fails to resolve contradictions, the reconstruction of self-identity is hindered, leading to coping dilemmas.As a core life context, family fertility expectations and support levels directly influence how participants interpret distress, adopt coping strategies, and adjust self-perception. Meanwhile, insufficient physician–patient communication creates an information gap, preventing participants from forming an accurate understanding of the relationship between treatment and fertility, and depriving them of professional guidance needed for identity reconstruction, thereby exacerbating decision-making dilemmas and identity confusion. Theme 4 Pathways to Distress Adaptation and Female Identity Reconstruction Although all 25 participants experienced varying degrees of fertility-related distress and coping dilemmas, 19 of them gradually developed pathways to adapt to distress and reconstruct their female identity over time, along with treatment progression and personal efforts. Based on interview examples, these can be categorized into four subthemes, all of which reflect participants’ reconstruction of the meaning of fertility and female identity, as well as the integration and restructuring of self-perception: 1) Adjusting fertility expectations and gradually accepting reality:Sixteen participants alleviated distress and accepted their situation by abandoning fertility desires, lowering expectations, or redirecting their reproductive intentions (e.g., adoption, focusing on other children). “I have gradually come to terms with it: life is more important than fertility. Even without children, I can still live a happy life. Now I focus on physical recovery and developing hobbies, gradually accepting myself and regaining my confidence.”(G3, 28 years old, unmarried, childless, 6 months post-treatment) 2) Redefining female self-worth and moving beyond a narrow fertility‑centered judgment:Eighteen participants broke free from the belief that “fertility equals female worth” and achieved identity reconstruction by focusing on career development, personal growth, and other family and social roles. “I used to think that a woman’s value lay only in childbearing. After my illness, I realized there are many dimensions to female worth. I returned to work and gained recognition from my leaders and colleagues. I am also a good wife and daughter. All these define my value.”(G7, 30 years old, married, childless, 1 year post-treatment) 3) Gaining growth from illness trauma and reconstructing the meaning of life:Fifteen participants reconstructed their meaning of life and accomplished identity reconstruction by cherishing life, feeling grateful, and sharing experiences to help others after undergoing trauma. “The pain of illness and infertility has helped me grow a great deal. I now cherish life and my family more. I joined a patient support group to share my experiences and found my value in helping others, which allowed me to move beyond distress.”(G5, 32 years old, married, childless, 9 months post-treatment) 4) Actively seeking information, psychological and multidisciplinary support:Seventeen participants effectively alleviated fertility-related distress and promoted identity reconstruction by proactively consulting physicians and reproductive specialists, seeking psychological intervention, joining peer support groups, and gaining understanding and support from family and partners . “I took the initiative to consult reproductive specialists to understand my ovarian function and fertility options; professional guidance relieved my anxiety. With the help of a psychologist, I adjusted my cognition, stopped self-denial, and gradually regained my confidence.”(G1, 25 years old, unmarried, childless, 5 months post-treatment) This study delineated a complete pathway from fertility-related distress to positive identity reconstruction among young women with breast cancer: 1. Identity fragmentation: Impaired fertility led to diminished female self-worth and identity disruption, representing the initial onset of distress. 2. Expectation adjustment: Participants gradually accepted the reality of illness and fertility limitations, lowered excessive fertility expectations, and began to move beyond the single narrative that “fertility equals female value”. 3. Core value reconstruction: Participants reestablished a multidimensional sense of self-worth, shifting self-identity from reproductive function to multiple dimensions including career, family roles, and personal growth, thereby achieving core value reconstruction. 4. Post-traumatic growth and identity reconstruction: Participants ultimately attained post-traumatic growth, embraced self-acceptance, developed a stable and positive female identity, and completed a full transition from distress to adaptation. This pathway can provide a theoretical basis for targeted psychological interventions and identity reconstruction support in clinical practice. It corroborates the core assertion of interpretative phenomenology that “meaning can be reconstructed” and aligns with the reconstruction mechanism of identity theory. Through cognitive adjustment, meaning reconstruction, and external support, individuals can overcome identity crisis and achieve positive identity reconstruction, offering dual theoretical support for clinical interventions. Discussion Based on the dual framework of interpretative phenomenology and Erikson’s theory of identity formation, this study employed semi-structured in-depth interviews to systematically explore the lived experiences of fertility-related distress, the underlying mechanisms of female identity change, coping dilemmas, and pathways of identity reconstruction among Chinese women of reproductive age with breast cancer.The main findings were as follows:① Fertility-related distress among Chinese women of reproductive age with breast cancer exhibits distinct cultural characteristics, with identity fragmentation caused by impaired fertility as the core experience;② A bidirectional vicious cycle exists between fertility-related distress and negative changes in female identity;③ A progressive pathway of female identity reconstruction consistent with the Chinese cultural context was identified. This study addresses gaps in the existing literature, which has largely focused on Western populations, relied predominantly on quantitative methods, and insufficiently explored the internal psychological mechanisms underlying identity changes[ 16 ]. It provides localized evidence in the field of female oncologic reproductive health, and offers theoretical foundations and practical implications for developing psychological intervention models tailored to Confucian cultural backgrounds. 4.1 Localized Characteristics of Fertility-Related Distress in Chinese Women of Reproductive Age with Breast Cancer This study reveals that fertility-related distress among Chinese women of reproductive age with breast cancer is multidimensional, with identity fragmentation as its core component, representing the key localized feature distinguishing this research from existing similar studies. In current Western research, fertility-related distress in women of reproductive age with breast cancer is mostly defined as emotional disturbance caused by disrupted family planning and unfulfilled fertility desires, with psychological impact largely limited to the event itself and relatively mild effects on overall self-identity [ 17 ]. In contrast, this study found that distress stemming from impaired fertility among Chinese patients does not merely arise from the loss of reproductive opportunities, but from deep-rooted gender norms in traditional Chinese family culture emphasizing lineage continuity and maternal supremacy. Fertility is not merely an individual choice but a core family responsibility and primary carrier of self-worth. Female identity is deeply bound to the maternal role and the duty of family continuation. Loss of fertility directly leads to the collapse of this core identity carrier, resulting in intense self-denial and feelings of incompleteness[ 18 ]. This finding aligns with the central tenet of interpretative phenomenology that an individual’s lived experience is shaped by their cultural and historical context, and also corroborates Erikson’s identity theory that sociocultural norms serve as a key determinant of identity construction [ 19 ]. Previous domestic quantitative studies have only reported high prevalence of fertility concerns in this population without exploring the underlying psychological motivations [ 20 ]. This study clarifies that identity fragmentation is the root cause of fertility-related distress, addressing gaps in the existing literature. Furthermore, this study identified a prevalent clinical tendency in China to prioritize oncological treatment over fertility-related care, resulting in more than 70% of participants lacking professional information on fertility preservation, post-treatment reproductive safety, and genetic risk prevention, further exacerbating anxiety and identity confusion. This is consistent with findings from multiple domestic studies [ 21 ]. Inadequate information prevents patients from forming stable and clear perceptions of fertility and cancer treatment, intensifying feelings of uncertainty about the future and cognitive dissonance. This indicates an obvious unmet need for reproductive health and psychological support in current clinical practice, representing a key direction for future improvements in clinical care. 4.2 Bidirectional Vicious Cycle Mechanism Between Fertility-Related Distress and Female Identity Change Core Innovative Finding of This Study This study revealed a bidirectional vicious cycle among Chinese women of reproductive age with breast cancer: impaired fertility → fertility-related distress → negative changes in self-identity → identity confusion → further aggravated fertility-related distress. This mechanism was observed in all participants and was strongly supported by the dual theoretical framework. Theoretically, interpretative phenomenology emphasizes a dynamic mutual construction between an individual’s subjective experience and meaning-making of events [ 22 ]. For participants in this study, impaired fertility acted as the triggering event. Participants interpreted this event through the lens of traditional fertility culture, resulting in multidimensional fertility-related distress. Such distress directly challenged their inherent identity that “womanhood equals motherhood”, leading to the deconstruction and negative transformation of female identity. Conversely, negative identity perceptions led to more negative meaning-making of fertility impairment, further amplifying distress and closing the cycle. Erikson’s identity theory provides a core developmental psychological explanation for this mechanism. Women of reproductive age are in early adulthood, whose central developmental tasks include establishing intimate relationships, fulfilling family roles, and forming a stable and coherent self-identity [ 23 ]. For Chinese women, the reproductive and maternal roles constitute a central part of self-identity at this stage. As a major adverse life event, impaired fertility directly disrupts their original self-identity balance and triggers identity crisis. Negative emotions derived from identity crisis, such as self-denial, inferiority, and role confusion, further intensify fertility-related distress, ultimately reinforcing the vicious cycle[ 24 ]. Previous quantitative studies only confirmed correlations between fertility concerns, identity confusion, and psychological distress, but failed to reveal the dynamic bidirectional mechanism or interpret its underlying logic within the Chinese cultural context [ 25 ]. Grounded in the dual theoretical framework, this study identified the foundations of this vicious cycle: the deep entanglement of female identity and reproductive roles in Chinese culture serves as the cultural root, while insufficient external support from families and the healthcare system acts as a critical reinforcing factor. This finding provides a clear therapeutic target for clinical psychological intervention—to break the vicious cycle, both the alleviation of fertility-related distress and the positive reconstruction of female identity are essential and indispensable. 4.3 Multidimensional Influencing Factors of Coping Dilemmas and Clinical Intervention Targets This study found that participants commonly faced multiple intertwined dilemmas when coping with fertility-related distress and identity changes. Based on the dual theoretical framework, these dilemmas essentially stemmed from combined effects of internal cognitive conflicts and deficiencies in the external support system during patients’ self-identity reconstruction. The core influencing factors can be summarized at three levels: individual, family, and medical, each corresponding to clear clinical intervention targets. At the individual level, the rigid unidimensional cognition that “fertility equals female value” was the central barrier to patients’ coping. This suggests that the primary target of clinical intervention is to help patients adjust fertility expectations through cognitive-behavioral interventions, break the one-dimensional evaluation system of female value, and lay a cognitive foundation for identity reconstruction [ 26 ]. At the family level, excessive fertility expectations from family members and insufficient empathic support for patients’ psychological distress posed major obstacles to identity reconstruction. This is consistent with Erikson’s theory that “support from significant others is a core condition for individual identity construction” [ 28 ]. Previous studies have confirmed that family support can significantly alleviate fertility-related anxiety among breast cancer patients, indicating that clinical interventions should include the family system. Synchronized health education for families can help relatives understand patients’ psychological pain, reduce unreasonable fertility expectations, and build a collaborative supportive family environment [ 27 ]. At the medical level, the lack of a multidisciplinary support system was the key reason for patients’ information shortage and decision-making dilemmas. This suggests that clinical practice should establish a multidisciplinary team (MDT) model involving breast surgery, reproductive medicine, psychology, and other specialties. Fertility counseling, reproductive risk assessment, and psychological counseling should be integrated into the whole-course management of women of reproductive age with breast cancer, filling the service gaps in the current diagnosis and treatment model [ 28 ]. 4 Progressive Pathway of Female Identity Reconstruction and Its Clinical Practice Value Although participants commonly faced multiple coping dilemmas, more than 70% of patients developed effective pathways to adapt to distress and reconstruct female identity through self-adjustment and external support. The four core pathways identified in this study constitute a progressive identity reconstruction model structured as prerequisite foundation – core key – advanced sublimation – external guarantee, providing a clear practical framework for developing localized and feasible psychological interventions in clinical settings. Among them, expectation adjustment serves as the prerequisite foundation for identity reconstruction. By adjusting fertility expectations and accepting the reality of impaired fertility, patients relieved fertility-related distress at its source, consistent with findings by Catherine B et al. [ 29 ].Self-worth reconstruction is the core key to breaking the vicious cycle. By breaking the unidimensional cognition that “fertility equals female value” and shifting focus to career development, personal growth, and other family and social roles, patients reconstructed female identity from a fertility-centered orientation to one centered on individual multidimensional value [ 30 ].Post-traumatic growth and life meaning reconstruction represent the advanced sublimation of identity reconstruction. Patients rethought the meaning of life amid illness trauma and achieved deep integration of self-identity through peer support and social participation [ 31 ].Actively seeking multidisciplinary support acts as an important external guarantee, providing sufficient professional and emotional support for patients’ cognitive adjustment and identity reconstruction [ 32 ]. Most previous domestic studies focused on influencing factors of post-traumatic growth in breast cancer patients but failed to clarify the specific pathways and internal logic of female identity reconstruction underlying such growth [ 33 ]. This study clearly delineates the complete psychological trajectory from identity fragmentation to reconstruction. Clinically, personalized staged interventions can be developed based on this progressive model: • For patients in the acute distress phase immediately after diagnosis, priority is given to emotional counseling and expectation adjustment; • For patients during treatment with severe identity confusion, cognitive interventions are emphasized to guide them in reshaping multidimensional female self-worth; • For patients in the rehabilitation phase, post-traumatic growth via peer support is encouraged.Multidisciplinary professional support and family support guidance are provided throughout the entire course of care. Clinical implications This study has important clinical implications for fertility care and psychological support of reproductive-age women with breast cancer in China. First, healthcare providers should perform routine screening for fertility distress and identity confusion at diagnosis, before treatment. Attention should be paid to both physical fertility risks and underlying psychological burden. Second, multidisciplinary teams including oncologists, fertility specialists, and counselors should deliver culturally sensitive fertility counseling that accounts for traditional family values and motherhood expectations. Third, targeted psychological interventions are needed to support positive female identity reconstruction beyond the maternal role, helping patients reduce guilt and rebuild self-worth. Fourth, family involvement should be encouraged to reduce social pressure, and long-term psycho-oncological support services should be established to improve mental health and quality of life. Overall, comprehensive, patient-centered, and culturally appropriate care that integrates fertility protection, psychological support, and identity reconstruction should be incorporated into routine clinical practice. Limitations This study has several limitations. First, the sample was mainly recruited from northern China and included a relatively high proportion of participants with higher education, which may limit the transferability of findings to women with lower education or from other regions. Second, this was a cross-sectional qualitative study that captured experiences at a single time point; longitudinal studies are needed to explore dynamic changes in distress and identity reconstruction across the illness trajectory. Third, most interviews were conducted online, which may have limited the collection of non-verbal information. Future research Future studies may consider: (1) conducting multi-center qualitative studies with larger and more diverse samples; (2) performing longitudinal follow-up to explore the dynamic process of identity reconstruction; (3) using mixed-methods designs to verify the vicious cycle mechanism; (4) developing and testing culturally adapted psychological interventions based on the reconstruction pathway; and (5) focusing on underserved populations such as rural women to promote equitable care. Conclusion This qualitative study demonstrates that fertility-related distress among Chinese reproductive-age women with breast cancer is culturally specific, with identity fragmentation as the core experience. A bidirectional vicious cycle exists between fertility-related distress and negative female identity changes. A progressive pathway toward positive identity reconstruction includes expectation adjustment, self-value remodeling, post-traumatic growth, and proactive multidisciplinary support-seeking. Multidisciplinary clinical care is recommended to alleviate distress, facilitate identity reconstruction, and improve long-term quality of life. Declarations Ethics approval and consent to participate Ethical approval was obtained from the Ethics Committee of Shanxi Bethune Hospital (reference number: YXLL-2026-026). The study was performed in accordance with the Declaration of Helsinki. All participants provided written informed consent prior to participation. Consent for publication Written informed consent for publication was obtained from all participants included in this study. Competing interests The authors declare that they have no competing interests. Author contributions Jun Guo contributed to study design, data collection, data analysis, and manuscript writing. Hulin Liu contributed to study supervision, conceptualization, and manuscript revision. All authors have read and approved the final manuscript. Acknowledgements We sincerely thank all participants for their generous support and participation in this study. Funding This study was supported by the Innovation Project of Henan High-Performance Medical Device Innovation Consortium (Project number: TR-2025-01-023). Availability of data and materials The datasets generated and analyzed during the current study are not publicly available to protect the privacy and confidentiality of participants. De-identified data are available from the corresponding author on reasonable request. The English version of the interview guide is provided as supplementary material. References Filho AM, Laversanne M, Ferlay J, Colombet M, Piñeros M, Znaor A, Parkin DM, Soerjomataram I, Bray F: The GLOBOCAN 2022 cancer estimates: Data sources, methods, and a snapshot of the cancer burden worldwide . INT J CANCER 2025, 156 (7):1336-1346. [Chinese consensus guidelines for breast cancer in young women: clinical practice and fertility preservation] . Zhonghua Zhong Liu Za Zhi 2019, 41 (7):486-495. Zhang S, Guclu SB, Lipsyc-Sharf M, Kapoor NS: Pregnancy and breast cancer in young women: current updates and future directions . THER ADV MED ONCOL 2025, 17 :22814709. Esserman LJ, Fiscalini AS, Naeim A, Van'T VL, Kaster A, Scheuner MT, LaCroix AZ, Borowsky AD, Anton-Culver H, Olopade OI et al : Risk-Based vs Annual Breast Cancer Screening: The WISDOM Randomized Clinical Trial . JAMA-J AM MED ASSOC 2026, 335 (9):763-774. Slamat R, Bracke P, Ceuterick M: "Mother in the making": Motherhood performativity of childless women in rural Pakistan . PLOS ONE 2026, 21 (2):e326698. Hu L, Xu B, Chau PH, Lok K, Kwok J, Choi E, Lau Y: Reproductive Concerns Among Young Adult Women With Breast Cancer: A Systematic Review and Meta-Analysis . PSYCHO-ONCOLOGY 2024, 33 (8):e9304. Wang Z, Yang X, Hong X, He Y, Xu A, Jiang X, Wei Q: A Qualitative Study of Fertility Preservation Experience in Women with Breast Cancer . INT J WOMENS HEALTH 2025, 17 :1143-1155. Global burden of 292 causes of death in 204 countries and territories and 660 subnational locations, 1990-2023: a systematic analysis for the Global Burden of Disease Study 2023 . LANCET 2025, 406 (10513):1811-1872. Qiu J, Tang L, Li P, Fu J: An investigation into the reproductive concerns of young women with breast cancer . ASIA-PAC J ONCOL NUR 2022, 9 (6):100055. Zhang Q, Gao W, Li X, Wang D, Zhang L, Xu M, Liu Y, Han J: Motherhood role concerns in young women with breast cancer: a mixed-methods study . BMC WOMENS HEALTH 2025, 25 (1):313. Cuthbertson LM, Robb YA, Blair S: Theory and application of research principles and philosophical underpinning for a study utilising interpretative phenomenological analysis . RADIOGRAPHY 2020, 26 (2):e94-e102. Wheeler SC, Bechler CJ: Objects and self-identity . CURR OPIN PSYCHOL 2021, 39 :6-11. Graneheim UH, Lundman B: Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness . NURS EDUC TODAY 2004, 24 (2):105-112. Graneheim UH, Lindgren BM, Lundman B: Methodological challenges in qualitative content analysis: A discussion paper . NURS EDUC TODAY 2017, 56 :29-34. Olmos-Vega FM, Stalmeijer RE, Varpio L, Kahlke R: A practical guide to reflexivity in qualitative research: AMEE Guide No. 149 . MED TEACH 2022:1-11. Greaney ML, Sprunck-Harrild K, Ruddy KJ, Ligibel J, Barry WT, Baker E, Meyer M, Emmons KM, Partridge AH: Study protocol for Young & Strong: a cluster randomized design to increase attention to unique issues faced by young women with newly diagnosed breast cancer . BMC PUBLIC HEALTH 2015, 15 :37. Partridge AH, Ruddy KJ: Fertility and adjuvant treatment in young women with breast cancer . BREAST 2007, 16 Suppl 2 :S175-S181. Mordenfeld KN, Partridge AH, Sella T: Pregnancy after breast cancer: latest evidence and practical considerations . THER ADV MED ONCOL 2025, 17 :22791384. Li SS, Zhou ZT, Cheng L, Du WN, Pan ZQ, Zhang J: The Mediating Effect of Psychological Resilience and Coping Style on Fear of Recurrence and Reproductive Concerns in Breast Cancer Patients of Childbearing Age . PSYCHOL RES BEHAV MA 2024, 17 :3395-3403. Hu L, Xu B, Chau PH, Choi E: Reproductive concerns among young adult women with breast cancer: a systematic review protocol . BMJ OPEN 2023, 13 (7):e71160. Liu C, Liu C, Gao H, Yu X, Chen C, Lin H, Qiu L, Chen L, Tian H: Mediation Effects of Coping Styles on Fear of Progression and Reproductive Concerns in Breast Cancer Patients of Reproductive Age . ASIAN NURS RES 2023, 17 (5):245-252. Dos SR, Neves ET, Carnevale F: Qualitative methodologies in health research: interpretive referential of Patricia Benner . REV BRAS ENFERM 2016, 69 (1):178-182. Mitchell LL, Lodi-Smith J, Baranski EN, Whitbourne SK: Implications of identity resolution in emerging adulthood for intimacy, generativity, and integrity across the adult lifespan . PSYCHOL AGING 2021, 36 (5):545-556. Yao H, Chan C, Chan C: Childbearing importance: A qualitative study of women with infertility in China . RES NURS HEALTH 2018, 41 (1):69-77. Carr AL, Roberts S, Bonnell LN, Kolva E: Existential distress and meaning making among female breast cancer patients with cancer-related fertility concerns . PALLIAT SUPPORT CARE 2023, 21 (2):196-204. Facchin F, Buggio L, Dridi D, Vercellini P: A woman's worth: The psychological impact of beliefs about motherhood, female identity, and infertility on childless women with endometriosis . J HEALTH PSYCHOL 2021, 26 (7):1026-1034. Hammersen F, Pursche T, Fischer D, Katalinic A, Waldmann A: Psychosocial and family-centered support among breast cancer patients with dependent children . PSYCHO-ONCOLOGY 2021, 30 (3):361-368. Xiao Y, Gu C, Liu L, Zeng X: Relationships among fertility concerns, fear of cancer recurrence, social support, self-efficacy, and family resilience among Chinese adolescents and young adults with cancer: A structural equation modeling . PLOS ONE 2026, 21 (2):e341351. Vesztergom D, Nánássy L, Polgár C, Krádi A, Rosta V, Varga S, Novák Z: [Fertility preservation in female cancer patients.] . ORVOSI HETILAP 2023, 164 (28):1094-1101. Benedict C, Hahn AL, McCready A, Kelvin JF, Diefenbach M, Ford JS: Toward a theoretical understanding of young female cancer survivors' decision-making about family-building post-treatment . SUPPORT CARE CANCER 2020, 28 (10):4857-4867. Campbell-Enns H, Woodgate aR: The psychosocial experiences of women with breast cancer across the lifespan: a systematic review protocol . JBI Database System Rev Implement Rep 2015, 13 (1):112-121. Clur LS, Barnard A: Reconstructing a Meaningful Self: The Identity Work of People Living With Chronic Disease . QUAL HEALTH RES 2025, 35 (13):1410-1422. Huang S, Huang M, Long F, Wang F: Post-traumatic growth experience of breast cancer patients: A qualitative systematic review and meta-synthesis . PLOS ONE 2025, 20 (1):e316108. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9443174","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":639965484,"identity":"e9591cb9-7d1d-4c95-b2dc-501fa3323335","order_by":0,"name":"Jun Guo","email":"","orcid":"","institution":"Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Third Hospital of Shanxi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Guo","suffix":""},{"id":639965486,"identity":"3bc0a298-9806-408a-8cee-3e51ae13a025","order_by":1,"name":"Jinnan Gao","email":"","orcid":"","institution":"Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Third Hospital of Shanxi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jinnan","middleName":"","lastName":"Gao","suffix":""},{"id":639965490,"identity":"e8231b5d-78c9-48cd-af25-a7b5821b4ecd","order_by":2,"name":"Xiaojun Zhang","email":"","orcid":"","institution":"Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Third Hospital of Shanxi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xiaojun","middleName":"","lastName":"Zhang","suffix":""},{"id":639965492,"identity":"78030e21-eb5c-4048-9754-c9548305cd2f","order_by":3,"name":"Yan Gao","email":"","orcid":"","institution":"Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Third Hospital of Shanxi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Gao","suffix":""},{"id":639965493,"identity":"b54c86f6-87f7-4437-9bb3-be8df107e93a","order_by":4,"name":"Hulin Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0UlEQVRIiWNgGAWjYBACA2YGNgaGAgkGfgYQg+EAsVoMJBgkG4jWAjYcSBocIFoLO4/ZYx4Dizzj82fMHrypuMPA3957gOHnDnwO4zE35jGQKDa7kZZuOOfMMwaJM+cSGHvP4NViJg3UkrjtBvMxad62w0B/5RgwM7YRoWVz/8E2ad5/pGjZwJAMtKWBKC1sZZJzgFpmgP1y7DCPxJkzBgd78Wix7z+8TeJNRV1ifz8oxGoOy/G39xg++IlHCyrgASOiYgdJyygYBaNgFIwCDAAAUqxGNxMYL8gAAAAASUVORK5CYII=","orcid":"","institution":"Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Third Hospital of Shanxi Medical University","correspondingAuthor":true,"prefix":"","firstName":"Hulin","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2026-04-17 02:39:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9443174/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9443174/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109332139,"identity":"0ab25e2f-3275-4a22-806f-c483c2c514ec","added_by":"auto","created_at":"2026-05-15 16:13:29","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":107425,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe mechanism model of the interaction between fertility-related distress and changes in female identity\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9443174/v1/7cab057c40897256d80cd5c9.jpg"}],"financialInterests":"No competing interests reported.","formattedTitle":"Fertility-related distress and female identity reconstruction among reproductive-age women with breast cancer in China: a qualitative study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAccording to the 2022 Global Cancer Statistics (GLOBOCAN 2022), there were 2.3\u0026nbsp;million new breast cancer cases, accounting for 11.6% of all new cancer cases worldwide, ranking second among all cancers and first among female malignancies[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In China, breast cancer affects patients at a relatively young age, with a median age at diagnosis of 45\u0026ndash;49 years, approximately 10 years earlier than that in Western countries. Young patients account for a considerable proportion: those aged 35 years and below represent more than 10% of all breast cancer patients, while extremely young patients aged 25 years and below account for about 0.5%[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Young breast cancer patients often undertake key roles in their families and society and have high expectations for their quality of life[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. With advances in diagnosis and treatment, the cure rate of breast cancer has improved. Although conventional treatments such as chemotherapy, radiotherapy, and endocrine therapy can effectively control the disease and improve survival, they inevitably impair ovarian function, leading to a growing number of women of childbearing age with breast cancer facing the risk of impaired or even permanent loss of fertility[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor women, fertility is far more than a mere physiological reproductive function; it is also an important carrier for constructing self-identity, fulfilling family roles, and realizing social values, and is closely associated with women\u0026rsquo;s self-perception, family status, and social evaluation[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Fertility-related distress caused by impaired fertility is not a single emotional response, but a complex psychological experience involving multiple negative emotions such as anxiety, depression, grief, and self-denial. Studies have shown that such psychological distress not only directly impairs patients\u0026rsquo; treatment compliance and reduces therapeutic efficacy, but also exerts long-term adverse effects on their psychological status, significantly lowers their long-term postoperative quality of life, and even triggers a series of family conflicts and social maladjustment problems[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt present, some progress has been made in international and domestic research on fertility‑related issues among women of childbearing age with breast cancer. However, most studies have focused on the development and application of fertility preservation technologies and quantitative surveys of fertility intention, using quantitative research designs such as cross‑sectional studies and cohort studies that emphasize the distribution and correlations of relevant indicators[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In-depth exploration of fertility-related distress in this population, as well as qualitative investigations into the identity changes and psychological mechanisms underlying such distress, remains insufficient.\u003c/p\u003e \u003cp\u003eNotably, most existing research has been conducted within Western cultural contexts, neglecting the impact of China\u0026rsquo;s unique cultural and social environment on the psychological well‑being of women of childbearing age with breast cancer[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In traditional Chinese family values, continuing the family line and childbearing are often regarded as core responsibilities and key manifestations of women\u0026rsquo;s value. Coupled with widespread societal expectations of women\u0026rsquo;s maternal role in modern society, Chinese women with breast cancer of reproductive age not only endure trauma caused by the disease itself but also face multiple pressures from family and society when confronted with impaired fertility. This results in more complex psychological conflicts and identity confusion, and the manifestations and influencing factors of their fertility‑related distress show distinct local characteristics[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough several domestic studies have examined fertility concerns among young breast cancer patients, most are quantitative surveys that fail to deeply explore the mechanisms of identity change underlying such distress[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Therefore, an obvious research gap exists regarding in‑depth qualitative studies on fertility‑related distress and identity reconstruction among women of childbearing age with breast cancer under the Chinese cultural context.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eThis study adopted an interpretative phenomenological design as a qualitative research approach, with interpretative phenomenology as the core theoretical framework[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and integrated Erikson\u0026rsquo;s theory of identity formation to establish the research structure[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. It focused on the lived experiences of fertility-related distress and changes in female identity among Chinese women of childbearing age with breast cancer, and further explored their subjective feelings, underlying psychological mechanisms, and pathways of identity reconstruction.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants and recruitment\u003c/h3\u003e\n\u003cp\u003e This study was conducted in China.Inclusion criteria:Women of childbearing age aged 18\u0026ndash;49 years;Confirmed diagnosis of breast cancer by pathological examination;Clear consciousness, able to communicate fluently in Mandarin Chinese with basic verbal expression skills;Voluntary participation in the study, signed informed consent, and willingness to complete semi-structured interviews and subsequent data collection.Exclusion criteria:Patients with other malignant tumors as the primary diagnosis (breast cancer as secondary disease);Comorbid severe mental illness or cognitive impairment that prevents participation in interviews;Severe complications such as severe hepatic or renal insufficiency, cardiovascular or cerebrovascular diseases that hinder normal study participation;Individuals who refuse to\u003c/p\u003e \u003cp\u003e Participants were recruited via referrals from medical staff in the Breast Surgery Department and advertisements posted on the official WeChat public account of the Breast Surgery Department, a formal science popularization platform approved by the hospital\u0026rsquo;s ethics committee focusing on female reproductive health and cancer survivorship education with certain authority and influence. A total of 27 women expressed interest in participating in the study: 22 responded to the advertisements on the WeChat public account, and 5 were recruited through staff referrals. They received written study information and were screened with relevant questions to confirm eligibility. Finally, 25 women met the inclusion criteria and were enrolled in the study. provide informed consent or withdraw from the study midway.\u003c/p\u003e \u003cp\u003e Twenty participants were interviewed via Tencent Meeting video, three via telephone, and two through face-to-face interviews. All interviews were conducted by the researcher between October 15, 2025, and January 25, 2026. Interviews were audio-recorded and lasted 30\u0026ndash;60 minutes, with a median duration of 45 minutes.\u003c/p\u003e \u003cp\u003e All participants provided written informed consent prior to participation. Interview recordings, transcribed texts, and related research data were collected with the explicit consent of participants. Personal privacy information including names, exact age, contact details, and medical records was anonymized (coded as G1 to G25) to protect participant confidentiality, and the entire study was conducted in strict accordance with medical ethical principles. A semi-structured interview guide was developed specifically for this study according to the research purpose and relevant literature. The interview guide included four core sections: experiences of breast cancer and treatment, fertility-related distress, changes in female identity, coping dilemmas, and pathways of identity reconstruction. The full English version of the interview guide is provided as Supplementary Material 1.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData analysis was performed using qualitative content analysis as proposed by Graneheim and Lundman[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], focusing on identifying similarities and differences in participants\u0026rsquo; experiences regarding fertility-related distress and changes in female identity. First, the researcher repeatedly read all interview transcripts and field notes to fully grasp the overall context and core meaning of the data and gain an in-depth understanding of participants\u0026rsquo; subjective experiences. Based on this, meaning units relevant to the research topic were identified and extracted, condensed to capture their core significance, and assigned corresponding codes. All codes were then compared, categorized, and grouped into distinct categories. Examples of the coding and category development process are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eExample of the formation process of meaning units, codes and categories\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeaning unit\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCondensed meaning unit\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCode\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\"After being diagnosed with breast cancer, I kept worrying that the treatment would leave me unable to have children. I also feared the cancer might be hereditary and passed on to my child. The doctor did not explain in detail how to avoid these risks, and the more I thought about it, the more anxious I became.\"\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfter diagnosis, patients experienced significant anxiety due to concerns about loss of fertility and hereditary cancer risk, compounded by insufficient relevant information.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConcerns about fertility; Anxiety over hereditary risk;Anxiety caused by insufficient information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultidimensional profiles of fertility-related distress\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\"I have always believed that a woman's value lies in having children and being a mother. Now, because of this treatment, I may not be able to give birth. I feel less like a complete woman, and the more I think about it, the more inferior I feel, making it even harder to accept the reality of my illness.\"\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFertility-related distress leads to negative changes in self-identity and a sense of identity disruption, which in turn exacerbate the distress, forming a vicious cycle.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSense of identity disruption; Negative changes in self-identity;Exacerbated distress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFertility-related distress and changes in female identity interact with each other.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\"I want to preserve my fertility, but I fear it will interfere with cancer treatment. My family wants me to focus on treatment first, yet I do not want to give up the chance of becoming a mother. I cannot express myself clearly when talking to my doctors, and I feel extremely conflicted.\"\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThey face value conflicts between survival and fertility, uncertainty regarding the risks of fertility preservation, contradictions between family expectations and personal wishes, as well as inadequate doctor-patient communication.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026middot;Conflict between survival and fertility;Concerns about risks of fertility preservation\u003c/p\u003e \u003cp\u003eInadequate doctor-patient communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCoping dilemmas\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\"I gradually adjusted my mindset and stopped regarding childbearing as the only value of being a woman. I took the initiative to consult psychologists and multidisciplinary teams, learned to accept myself, and found my own meaning in life.\"\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThrough expectation adjustment, self-worth reconstruction, and active pursuit of multidisciplinary support, post-traumatic growth is achieved, and the reconstruction of female identity is completed.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExpectation adjustment\u003c/p\u003e \u003cp\u003eSelf-worth reconstruction\u003c/p\u003e \u003cp\u003eMultidisciplinary support\u003c/p\u003e \u003cp\u003ePost-traumatic growth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePathway of identity reconstruction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eData analysis was conducted jointly by the first author (JG) and a co-researcher (HL). The two researchers independently read and coded five interview transcripts, after which they held detailed discussions to compare coding results, verify coding logic and category assignments one by one, and reach a consensus. The remaining transcripts were then coded by the lead researcher. Manifest content (information directly and explicitly expressed in the text) was presented descriptively in the form of categories[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]; latent content (deep underlying meanings, emotions, and psychological mechanisms implied in the text) was interpreted at an explanatory level in the form of themes, focusing on the intrinsic relationship between fertility-related distress and changes in female identity.\u003c/p\u003e \u003cp\u003eThe prior perceptions of the first author (JG) were grounded in clinical experience and research accumulated as a medical professional and researcher in the field of psychological intervention for women of childbearing age with breast cancer. Over the years, as a clinical practitioner, the researcher has encountered and assisted numerous young breast cancer patients in addressing fertility-related distress and identity confusion. Such prior understanding facilitates the detection of subtle emotional and cognitive differences in participants\u0026rsquo; narratives. Meanwhile, the researcher explicitly acknowledged personal values and preconceptions to avoid subjective bias in the analytical process[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The co-researcher (HL) possessed clinical and research expertise in psychological nursing and cancer survivorship, offering diverse interpretative perspectives for data analysis and effectively compensating for the limitations of a single viewpoint.\u003c/p\u003e \u003cp\u003eThroughout the analysis process, the researcher and co-researcher engaged in continuous joint discussion and reflexivity, repeatedly verifying the rationality of codes, categories, and themes and revising analytical biases accordingly. Two experts in qualitative research were also invited to review the analytical findings, and the coding and theme development were further refined based on expert feedback to enhance the rigor and trustworthiness of the study.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eParticipants were recruited from different regions of China and varied in the duration of their breast cancer illness. Their ages ranged from 19 to 48 years, with a median age of 36 years. The time from breast cancer diagnosis to study enrollment ranged from 6 months to 5 years, with a median interval of 2 years. All participants were pathologically diagnosed with breast cancer, including 20 cases of invasive ductal carcinoma and 5 cases of other pathological types. During the interviews, 3 participants reported comorbid mild anxiety or depression in addition to their primary breast cancer diagnosis. Although the interviews focused on participants\u0026rsquo; lived experiences of fertility-related distress and changes in female identity, their narratives reflected complex life circumstances, indicating that other coexisting psychological or physical conditions may be intertwined with their overall experiences. Among the participants, 8 had 1 to 2 children and 17 had no children. Seventeen participants held a higher education qualification. Detailed demographic and clinical characteristics of the participants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBasic demographic and clinical characteristics of the research objects\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParticipants(n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7cases (28.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11cases (44.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e41\u0026ndash;48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7cases (28.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime from diagnosis to enrollment (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0.5-2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13cases (52.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.1-5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12cases (48.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathological type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInvasive ductal carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20cases (80.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5cases (20.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbid emotional problems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22cases (88.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild anxiety / depression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3cases (12.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChildless\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17cases (68.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;2 children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8cases (32.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher education (college diploma or above)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17cases (68.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSenior high school or below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8cases (32.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFour core themes were identified through data analysis: multidimensional manifestations of fertility-related distress, reciprocal influences between fertility-related distress and changes in female identity, dilemmas in coping, and pathways of identity reconstruction. These themes reflected the deep latent meanings in participants\u0026rsquo;narratives: complex negative emotions and psychological experiences resulting from impaired fertility; a vicious cycle between fertility-related distress and female identity; dilemmas amid multiple conflicts between fertility and survival, personal wishes and family expectations; and the post-traumatic process of seeking self-acceptance, reshaping identity, and exploring life meaning. Each theme comprised several categories, as detailed in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes and categories extracted from data analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultidimensional manifestations of fertility-related distress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSense of identity fragmentation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnxiety over time conflicts between treatment and fertility\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConcerns about genetic risks\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnxiety due to information scarcity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe reciprocal relationship between fertility-related distress and changes in female identity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative changes in self-identity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIdentity confusion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoping dilemmas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue conflict between survival and fertility\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUncertainty regarding the benefits and risks of fertility preservation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConflict between family expectations and personal wishes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInadequate doctor-patient communication\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSignificant differences exist in the level of support from family and partners\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathway of identity reconstruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExpectation adjustment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-worth reconstruction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRedefining female identity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost-traumatic Growth and the Reconstruction of Life Meaning\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTake the initiative to seek multidisciplinary support\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTheme 1 Multidimensional Manifestations of Fertility-Related Distress\u003c/p\u003e\n\u003cp\u003e1)Identity fragmentation caused by loss of fertility (n=25, including 16 nulliparous women and 9 parous women who had not completed their fertility plans): This represented the core distress among all participants who had not fulfilled their fertility intentions, characterized by intense self-denial, regret, and feelings of incompleteness. Strongly influenced by traditional Chinese values emphasizing maternal priority and carrying on the family line, participants universally regarded fertility as a central marker of female identity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eI have always believed that a woman ought to have a child in her lifetime; it is only natural. Now my doctor says it will be very difficult for me to conceive after treatment. I feel like I am incomplete, deprived of the most basic female function. I dare not join in when friends around me talk about pregnancy.\u003c/em\u003e\u003cem\u003e\u0026rdquo;\u003c/em\u003e\u003cem\u003e(G3,\u0026nbsp;\u003c/em\u003e28 years old, unmarried, nulliparous)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eSuch identity fragmentation essentially reflects an undermined construction of female identity and shaken self-awareness, representing the initial manifestation of an identity crisis\u003cem\u003e.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e2)Severe anxiety caused by time conflicts between treatment and fertility (n=22, including 8 undergoing treatment and 14 post-treatment): Women of childbearing age have a limited reproductive window, whereas breast cancer treatment requires a prolonged course and often impairs ovarian function, leaving participants caught in a distressing dilemma between lifesaving treatment and preserving fertility.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eI am 30 years old and originally planned to get pregnant next year. Now I am undergoing chemotherapy every day, and my doctor says I must wait at least 2 years after treatment before considering pregnancy. I am truly terrified that I will never be able to conceive. This anxiety torments me every day and often keeps me awake at night.\u003c/em\u003e\u003cem\u003e\u0026rdquo;\u003c/em\u003e\u003cem\u003e(G7, 30 years old, married, nulliparous, undergoing treatment)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Such anxiety stems from attachment to reproductive opportunities and fear of losing fertility hope, further exacerbating disturbances in self-perception.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3)\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003ePersistent concern about hereditary risk in offspring (n=18, including 7 with a family history of breast cancer): Participants commonly feared passing cancer on to their children, leaving them in the conflict of\u0026nbsp;\u0026ldquo;wanting to conceive but daring not to.\u0026rdquo;\u0026nbsp;\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eMy mother is a breast cancer patient, and my doctor said breast cancer can be hereditary. I am terrified that my child might develop this disease if I get pregnant, yet I desperately want a child of my own. This contradiction causes me great distress every day.\u003c/em\u003e\u003cem\u003e\u0026rdquo;\u003c/em\u003e\u003cem\u003e\u0026nbsp;(G5, 32 years old, married, nulliparous\u003c/em\u003e, \u003cem\u003ewith a maternal history of breast cancer)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Such concern reflects maternal instinct and also reveals participants\u0026rsquo;\u0026nbsp;doubt about their self-worth, as they worry about being unable to provide a healthy future for their offspring.\u003c/p\u003e\n\u003cp\u003e4) Confusion and anxiety caused by insufficient fertility-related information (n=20): Participants experienced confusion and helplessness due to a lack of professional guidance on fertility preservation and post-treatment reproductive recovery. One participant stated:\u0026nbsp;\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eAfter diagnosis, my doctor only told me to focus on treatment and never mentioned fertility preservation. I later heard from other patients that egg freezing was an option before chemotherapy, but I had already started treatment and it was too late. I do not know where to obtain reliable information, and I feel anxious every day.\u003c/em\u003e\u003cem\u003e\u0026rdquo;\u003c/em\u003e\u003cem\u003e\u0026nbsp;(G1, 25 years old, unmarried, childless, undergoing treatment)\u0026nbsp;\u003c/em\u003e The lack of information prevented participants from making reasonable judgments about their fertility prospects and exacerbated their distress.\u003c/p\u003e\n\u003cp\u003eThese multidimensional experiences of fertility-related distress are deeply intertwined with patients\u0026rsquo;\u0026nbsp;family and cultural perceptions as well as personal fertility expectations. This aligns with the core idea of interpretative phenomenology that\u0026nbsp;\u0026ldquo;experience and meaning are co-constructed\u0026rdquo;\u0026nbsp;and also corroborates the essence of identity theory: as a vital component of female self-identity, the loss of fertility directly disrupts an individual\u0026rsquo;s original self-concept system, leading to self-denial and self-doubt, laying the groundwork for subsequent identity crises.\u003c/p\u003e\n\u003cp\u003eTheme 2 Interactive Mechanism Between Fertility-Related Distress and Changes in Female Identity In‑depth analysis of interview data revealed that fertility‑related distress and changes in female identity did not exert a unidirectional influence, but rather interacted dynamically and formed a vicious cycle. This mechanism was observed among all 25 participants. Supported by interview excerpts and theoretical interpretation, the specific mechanism is described as follows:\u003c/p\u003e\n\u003cp\u003eImpaired fertility serves as the initial trigger for this cycle. When participants learned that their fertility was compromised or lost, they developed the aforementioned multidimensional fertility-related distress. Such distress directly disrupted their original perception of female identity, leading to negative changes in female identity, mainly manifested as feelings of identity fragmentation, unclear role positioning, and negation of self-worth. In turn, these negative changes in female identity further intensified fertility-related distress, forming a vicious cycle: \u0026ldquo;fertility impairment \u0026rarr; fertility-related distress \u0026rarr; negative changes in self-identity \u0026rarr; identity confusion \u0026rarr; further exacerbated distress\u0026rdquo; (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I used to be very confident and thought I would get pregnant and have a baby smoothly. But when my doctor said it would be very difficult for me to conceive after chemotherapy, I broke down completely and felt I was no longer a complete woman (identity fragmentation caused by fertility-related distress). This thought made me increasingly inferior and unwilling to interact with others. I cannot help crying whenever fertility comes to mind, which in turn makes me more afraid of treatment and worries that further negative changes in my identity will worsen my distress.\u0026rdquo;(G8, 31 years old, married, childless, undergoing treatment)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTheme 3 Dilemmas in Coping with Fertility-Related Distress and Identity Changes\u003c/p\u003e\n\u003cp\u003eAll 25 participants encountered varying degrees of dilemmas when coping with fertility-related distress and shifts in female identity. These dilemmas were intertwined and further hindered distress relief and identity reconstruction. Based on interview examples, they can be divided into five subthemes:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1)\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eValue conflict between survival needs and fertility desires:All participants faced the dilemma of prioritizing life‑saving treatment versus preserving fertility, which intensified their psychological distress.\u003cem\u003e\u0026ldquo;I want to preserve my fertility, especially since I am not married and have no children. However, my doctor insists that I must start chemotherapy immediately, which will result in permanent infertility. On one side is my life, and on the other is my wish to have children. I truly do not know how to choose and struggle with this decision every day.\u0026rdquo;(G4, 29 years old, unmarried, childless, undergoing treatment)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2)\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eUncertainty regarding the benefits and risks of fertility preservation:Fourteen childless participants aged \u0026le;35 years experienced decision-making dilemmas due to concerns about the success rate, cost, and future feasibility of egg or embryo cryopreservation\u003cem\u003e.\u0026ldquo;I wanted to undergo egg freezing before chemotherapy, but my doctor said the success rate is not 100% and the cost is high. My family is not well-off, and even if egg freezing is successful, I am unsure whether my body will be suitable for pregnancy after treatment. Such uncertainty makes me very hesitant.\u0026rdquo;(G6, 27 years old, unmarried, childless, undergoing treatment)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3)\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eConflict between family expectations and personal wishes:Twenty-one married participants experienced heavy family pressure, as fertility expectations from family members (especially older generations) clashed with their impaired fertility and reduced reproductive motivation\u003cem\u003e.\u0026ldquo;My parents-in-law had always hoped we would have a child. After they learned that I might be unable to conceive, I could clearly sense their disappointment. My mother also kept telling me that a woman must have children. Yet my physical condition does not allow it. This internal conflict leaves me feeling deeply depressed.\u0026rdquo;(G9, 33 years old, married, childless, 3 months post-treatment)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4)\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eInsufficient physician-patient communication and lack of tailored guidance:Nineteen participants reported that clinicians focused primarily on disease management while neglecting their fertility-related needs and failing to provide professional counseling, which aggravated their confusion and distress\u003cem\u003e.\u0026ldquo;During every chemotherapy visit, doctors only cared about my disease progress and never asked about my fertility-related concerns. I also felt embarrassed to bring it up on my own initiative. I badly needed professional guidance but could not receive any, leaving me confused every day.\u0026rdquo;(G2, 26 years old, unmarried, childless, undergoing treatment)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e5)\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eSignificant disparities in family and partner support:Seventeen participants felt lonely and helpless due to insufficient emotional support, as their partners and family members failed to understand their distress and identity confusion\u003cem\u003e.\u0026ldquo;My husband supports me on the surface but cannot truly comprehend my pain. He often says \u0026lsquo;it doesn\u0026rsquo;t matter whether we have children or not\u0026rsquo;. He does not understand what infertility means to me. When I try to confide in him, he always thinks I am being oversensitive. This lack of understanding makes me feel extremely lonely.\u0026rdquo;(G10, 31 years old, married, childless, undergoing treatment)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese dilemmas stem from conflicting meaning constructions among participants regarding \u0026ldquo;the meaning of survival\u0026rdquo;, \u0026ldquo;the meaning of fertility\u0026rdquo;, and \u0026ldquo;the value of womanhood\u0026rdquo;. This not only corroborates the view of interpretative phenomenology that \u0026ldquo;experience is shaped by context and interpersonal relationships\u0026rdquo;, but also aligns with the core tenet of identity theory: the construction and reconstruction of individual identity require the synergy of external support (family, medical staff) and internal cognitive adjustment. When external support is inadequate and internal cognition fails to resolve contradictions, the reconstruction of self-identity is hindered, leading to coping dilemmas.As a core life context, family fertility expectations and support levels directly influence how participants interpret distress, adopt coping strategies, and adjust self-perception. Meanwhile, insufficient physician\u0026ndash;patient communication creates an information gap, preventing participants from forming an accurate understanding of the relationship between treatment and fertility, and depriving them of professional guidance needed for identity reconstruction, thereby exacerbating decision-making dilemmas and identity confusion.\u003c/p\u003e\n\u003cp\u003eTheme 4 Pathways to Distress Adaptation and Female Identity Reconstruction\u003c/p\u003e\n\u003cp\u003eAlthough all 25 participants experienced varying degrees of fertility-related distress and coping dilemmas, 19 of them gradually developed pathways to adapt to distress and reconstruct their female identity over time, along with treatment progression and personal efforts. Based on interview examples, these can be categorized into four subthemes, all of which reflect participants\u0026rsquo; reconstruction of the meaning of fertility and female identity, as well as the integration and restructuring of self-perception:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1)\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eAdjusting fertility expectations and gradually accepting reality:Sixteen participants alleviated distress and accepted their situation by abandoning fertility desires, lowering expectations, or redirecting their reproductive intentions (e.g., adoption, focusing on other children). \u003cem\u003e\u0026nbsp;\u0026ldquo;I have gradually come to terms with it: life is more important than fertility. Even without children, I can still live a happy life. Now I focus on physical recovery and developing hobbies, gradually accepting myself and regaining my confidence.\u0026rdquo;(G3, 28 years old, unmarried, childless, 6 months post-treatment)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2)\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eRedefining female self-worth and moving beyond a narrow fertility‑centered judgment:Eighteen participants broke free from the belief that \u0026ldquo;fertility equals female worth\u0026rdquo; and achieved identity reconstruction by focusing on career development, personal growth, and other family and social roles.\u003cem\u003e\u0026nbsp; \u0026ldquo;I used to think that a woman\u0026rsquo;s value lay only in childbearing. After my illness, I realized there are many dimensions to female worth. I returned to work and gained recognition from my leaders and colleagues. I am also a good wife and daughter. All these define my value.\u0026rdquo;(G7, 30 years old, married, childless, 1 year post-treatment)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3)\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eGaining growth from illness trauma and reconstructing the meaning of life:Fifteen participants reconstructed their meaning of life and accomplished identity reconstruction by cherishing life, feeling grateful, and sharing experiences to help others after undergoing trauma. \u003cem\u003e\u0026nbsp;\u0026ldquo;The pain of illness and infertility has helped me grow a great deal. I now cherish life and my family more. I joined a patient support group to share my experiences and found my value in helping others, which allowed me to move beyond distress.\u0026rdquo;(G5, 32 years old, married, childless, 9 months post-treatment)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4)\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eActively seeking information, psychological and multidisciplinary support:Seventeen participants effectively alleviated fertility-related distress and promoted identity reconstruction by proactively consulting physicians and reproductive specialists, seeking psychological intervention, joining peer support groups, and gaining understanding and support from family and partners\u003cem\u003e. \u0026nbsp;\u0026ldquo;I took the initiative to consult reproductive specialists to understand my ovarian function and fertility options; professional guidance relieved my anxiety. With the help of a psychologist, I adjusted my cognition, stopped self-denial, and gradually regained my confidence.\u0026rdquo;(G1, 25 years old, unmarried, childless, 5 months post-treatment)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study delineated a complete pathway from fertility-related distress to positive identity reconstruction among young women with breast cancer: 1. Identity fragmentation: Impaired fertility led to diminished female self-worth and identity disruption, representing the initial onset of distress. 2. Expectation adjustment: Participants gradually accepted the reality of illness and fertility limitations, lowered excessive fertility expectations, and began to move beyond the single narrative that \u0026ldquo;fertility equals female value\u0026rdquo;. 3. Core value reconstruction: Participants reestablished a multidimensional sense of self-worth, shifting self-identity from reproductive function to multiple dimensions including career, family roles, and personal growth, thereby achieving core value reconstruction. 4. Post-traumatic growth and identity reconstruction: Participants ultimately attained post-traumatic growth, embraced self-acceptance, developed a stable and positive female identity, and completed a full transition from distress to adaptation. \u0026nbsp;This pathway can provide a theoretical basis for targeted psychological interventions and identity reconstruction support in clinical practice. It corroborates the core assertion of interpretative phenomenology that \u0026ldquo;meaning can be reconstructed\u0026rdquo; and aligns with the reconstruction mechanism of identity theory. Through cognitive adjustment, meaning reconstruction, and external support, individuals can overcome identity crisis and achieve positive identity reconstruction, offering dual theoretical support for clinical interventions.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eBased on the dual framework of interpretative phenomenology and Erikson\u0026rsquo;s theory of identity formation, this study employed semi-structured in-depth interviews to systematically explore the lived experiences of fertility-related distress, the underlying mechanisms of female identity change, coping dilemmas, and pathways of identity reconstruction among Chinese women of reproductive age with breast cancer.The main findings were as follows:① Fertility-related distress among Chinese women of reproductive age with breast cancer exhibits distinct cultural characteristics, with identity fragmentation caused by impaired fertility as the core experience;② A bidirectional vicious cycle exists between fertility-related distress and negative changes in female identity;③ A progressive pathway of female identity reconstruction consistent with the Chinese cultural context was identified. This study addresses gaps in the existing literature, which has largely focused on Western populations, relied predominantly on quantitative methods, and insufficiently explored the internal psychological mechanisms underlying identity changes[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. It provides localized evidence in the field of female oncologic reproductive health, and offers theoretical foundations and practical implications for developing psychological intervention models tailored to Confucian cultural backgrounds.\u003c/p\u003e\u003cp\u003e4.1 Localized Characteristics of Fertility-Related Distress in Chinese Women of Reproductive Age with Breast Cancer This study reveals that fertility-related distress among Chinese women of reproductive age with breast cancer is multidimensional, with identity fragmentation as its core component, representing the key localized feature distinguishing this research from existing similar studies. In current Western research, fertility-related distress in women of reproductive age with breast cancer is mostly defined as emotional disturbance caused by disrupted family planning and unfulfilled fertility desires, with psychological impact largely limited to the event itself and relatively mild effects on overall self-identity [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In contrast, this study found that distress stemming from impaired fertility among Chinese patients does not merely arise from the loss of reproductive opportunities, but from deep-rooted gender norms in traditional Chinese family culture emphasizing lineage continuity and maternal supremacy. Fertility is not merely an individual choice but a core family responsibility and primary carrier of self-worth. Female identity is deeply bound to the maternal role and the duty of family continuation. Loss of fertility directly leads to the collapse of this core identity carrier, resulting in intense self-denial and feelings of incompleteness[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This finding aligns with the central tenet of interpretative phenomenology that an individual\u0026rsquo;s lived experience is shaped by their cultural and historical context, and also corroborates Erikson\u0026rsquo;s identity theory that sociocultural norms serve as a key determinant of identity construction [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Previous domestic quantitative studies have only reported high prevalence of fertility concerns in this population without exploring the underlying psychological motivations [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This study clarifies that identity fragmentation is the root cause of fertility-related distress, addressing gaps in the existing literature. Furthermore, this study identified a prevalent clinical tendency in China to prioritize oncological treatment over fertility-related care, resulting in more than 70% of participants lacking professional information on fertility preservation, post-treatment reproductive safety, and genetic risk prevention, further exacerbating anxiety and identity confusion. This is consistent with findings from multiple domestic studies [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Inadequate information prevents patients from forming stable and clear perceptions of fertility and cancer treatment, intensifying feelings of uncertainty about the future and cognitive dissonance. This indicates an obvious unmet need for reproductive health and psychological support in current clinical practice, representing a key direction for future improvements in clinical care.\u003c/p\u003e\u003cp\u003e4.2 Bidirectional Vicious Cycle Mechanism Between Fertility-Related Distress and Female Identity Change Core Innovative Finding of This Study This study revealed a bidirectional vicious cycle among Chinese women of reproductive age with breast cancer: impaired fertility \u0026rarr; fertility-related distress \u0026rarr; negative changes in self-identity \u0026rarr; identity confusion \u0026rarr; further aggravated fertility-related distress. This mechanism was observed in all participants and was strongly supported by the dual theoretical framework. Theoretically, interpretative phenomenology emphasizes a dynamic mutual construction between an individual\u0026rsquo;s subjective experience and meaning-making of events [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. For participants in this study, impaired fertility acted as the triggering event. Participants interpreted this event through the lens of traditional fertility culture, resulting in multidimensional fertility-related distress. Such distress directly challenged their inherent identity that \u0026ldquo;womanhood equals motherhood\u0026rdquo;, leading to the deconstruction and negative transformation of female identity. Conversely, negative identity perceptions led to more negative meaning-making of fertility impairment, further amplifying distress and closing the cycle. Erikson\u0026rsquo;s identity theory provides a core developmental psychological explanation for this mechanism. Women of reproductive age are in early adulthood, whose central developmental tasks include establishing intimate relationships, fulfilling family roles, and forming a stable and coherent self-identity [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. For Chinese women, the reproductive and maternal roles constitute a central part of self-identity at this stage. As a major adverse life event, impaired fertility directly disrupts their original self-identity balance and triggers identity crisis. Negative emotions derived from identity crisis, such as self-denial, inferiority, and role confusion, further intensify fertility-related distress, ultimately reinforcing the vicious cycle[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Previous quantitative studies only confirmed correlations between fertility concerns, identity confusion, and psychological distress, but failed to reveal the dynamic bidirectional mechanism or interpret its underlying logic within the Chinese cultural context [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Grounded in the dual theoretical framework, this study identified the foundations of this vicious cycle: the deep entanglement of female identity and reproductive roles in Chinese culture serves as the cultural root, while insufficient external support from families and the healthcare system acts as a critical reinforcing factor. This finding provides a clear therapeutic target for clinical psychological intervention\u0026mdash;to break the vicious cycle, both the alleviation of fertility-related distress and the positive reconstruction of female identity are essential and indispensable.\u003c/p\u003e\u003cp\u003e4.3 Multidimensional Influencing Factors of Coping Dilemmas and Clinical Intervention Targets\u003c/p\u003e\u003cp\u003eThis study found that participants commonly faced multiple intertwined dilemmas when coping with fertility-related distress and identity changes. Based on the dual theoretical framework, these dilemmas essentially stemmed from combined effects of internal cognitive conflicts and deficiencies in the external support system during patients\u0026rsquo; self-identity reconstruction. The core influencing factors can be summarized at three levels: individual, family, and medical, each corresponding to clear clinical intervention targets.\u003c/p\u003e\u003cp\u003eAt the individual level, the rigid unidimensional cognition that \u0026ldquo;fertility equals female value\u0026rdquo; was the central barrier to patients\u0026rsquo; coping. This suggests that the primary target of clinical intervention is to help patients adjust fertility expectations through cognitive-behavioral interventions, break the one-dimensional evaluation system of female value, and lay a cognitive foundation for identity reconstruction [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAt the family level, excessive fertility expectations from family members and insufficient empathic support for patients\u0026rsquo; psychological distress posed major obstacles to identity reconstruction. This is consistent with Erikson\u0026rsquo;s theory that \u0026ldquo;support from significant others is a core condition for individual identity construction\u0026rdquo; [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Previous studies have confirmed that family support can significantly alleviate fertility-related anxiety among breast cancer patients, indicating that clinical interventions should include the family system. Synchronized health education for families can help relatives understand patients\u0026rsquo; psychological pain, reduce unreasonable fertility expectations, and build a collaborative supportive family environment [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAt the medical level, the lack of a multidisciplinary support system was the key reason for patients\u0026rsquo; information shortage and decision-making dilemmas. This suggests that clinical practice should establish a multidisciplinary team (MDT) model involving breast surgery, reproductive medicine, psychology, and other specialties. Fertility counseling, reproductive risk assessment, and psychological counseling should be integrated into the whole-course management of women of reproductive age with breast cancer, filling the service gaps in the current diagnosis and treatment model [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e4 Progressive Pathway of Female Identity Reconstruction and Its Clinical Practice Value Although participants commonly faced multiple coping dilemmas, more than 70% of patients developed effective pathways to adapt to distress and reconstruct female identity through self-adjustment and external support. The four core pathways identified in this study constitute a progressive identity reconstruction model structured as prerequisite foundation \u0026ndash; core key \u0026ndash; advanced sublimation \u0026ndash; external guarantee, providing a clear practical framework for developing localized and feasible psychological interventions in clinical settings. Among them, expectation adjustment serves as the prerequisite foundation for identity reconstruction. By adjusting fertility expectations and accepting the reality of impaired fertility, patients relieved fertility-related distress at its source, consistent with findings by Catherine B et al. [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].Self-worth reconstruction is the core key to breaking the vicious cycle. By breaking the unidimensional cognition that \u0026ldquo;fertility equals female value\u0026rdquo; and shifting focus to career development, personal growth, and other family and social roles, patients reconstructed female identity from a fertility-centered orientation to one centered on individual multidimensional value [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].Post-traumatic growth and life meaning reconstruction represent the advanced sublimation of identity reconstruction. Patients rethought the meaning of life amid illness trauma and achieved deep integration of self-identity through peer support and social participation [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].Actively seeking multidisciplinary support acts as an important external guarantee, providing sufficient professional and emotional support for patients\u0026rsquo; cognitive adjustment and identity reconstruction [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Most previous domestic studies focused on influencing factors of post-traumatic growth in breast cancer patients but failed to clarify the specific pathways and internal logic of female identity reconstruction underlying such growth [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. This study clearly delineates the complete psychological trajectory from identity fragmentation to reconstruction. Clinically, personalized staged interventions can be developed based on this progressive model: \u0026bull; For patients in the acute distress phase immediately after diagnosis, priority is given to emotional counseling and expectation adjustment; \u0026bull; For patients during treatment with severe identity confusion, cognitive interventions are emphasized to guide them in reshaping multidimensional female self-worth; \u0026bull; For patients in the rehabilitation phase, post-traumatic growth via peer support is encouraged.Multidisciplinary professional support and family support guidance are provided throughout the entire course of care.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eClinical implications\u003c/h2\u003e \u003cp\u003e This study has important clinical implications for fertility care and psychological support of reproductive-age women with breast cancer in China.\u003c/p\u003e\u003cp\u003eFirst, healthcare providers should perform routine screening for fertility distress and identity confusion at diagnosis, before treatment. Attention should be paid to both physical fertility risks and underlying psychological burden.\u003c/p\u003e\u003cp\u003eSecond, multidisciplinary teams including oncologists, fertility specialists, and counselors should deliver culturally sensitive fertility counseling that accounts for traditional family values and motherhood expectations.\u003c/p\u003e\u003cp\u003eThird, targeted psychological interventions are needed to support positive female identity reconstruction beyond the maternal role, helping patients reduce guilt and rebuild self-worth.\u003c/p\u003e\u003cp\u003eFourth, family involvement should be encouraged to reduce social pressure, and long-term psycho-oncological support services should be established to improve mental health and quality of life.\u003c/p\u003e\u003cp\u003eOverall, comprehensive, patient-centered, and culturally appropriate care that integrates fertility protection, psychological support, and identity reconstruction should be incorporated into routine clinical practice.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThis study has several limitations. First, the sample was mainly recruited from northern China and included a relatively high proportion of participants with higher education, which may limit the transferability of findings to women with lower education or from other regions. Second, this was a cross-sectional qualitative study that captured experiences at a single time point; longitudinal studies are needed to explore dynamic changes in distress and identity reconstruction across the illness trajectory. Third, most interviews were conducted online, which may have limited the collection of non-verbal information.\u003c/p\u003e\u003cp\u003e Future research Future studies may consider: (1) conducting multi-center qualitative studies with larger and more diverse samples; (2) performing longitudinal follow-up to explore the dynamic process of identity reconstruction; (3) using mixed-methods designs to verify the vicious cycle mechanism; (4) developing and testing culturally adapted psychological interventions based on the reconstruction pathway; and (5) focusing on underserved populations such as rural women to promote equitable care.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis qualitative study demonstrates that fertility-related distress among Chinese reproductive-age women with breast cancer is culturally specific, with identity fragmentation as the core experience. A bidirectional vicious cycle exists between fertility-related distress and negative female identity changes. A progressive pathway toward positive identity reconstruction includes expectation adjustment, self-value remodeling, post-traumatic growth, and proactive multidisciplinary support-seeking. Multidisciplinary clinical care is recommended to alleviate distress, facilitate identity reconstruction, and improve long-term quality of life.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Ethics Committee of Shanxi Bethune Hospital (reference number: YXLL-2026-026). The study was performed in accordance with the Declaration of Helsinki. All participants provided written informed consent prior to participation.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from all participants included in this study.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eAuthor contributions\u003c/p\u003e\n\u003cp\u003eJun Guo contributed to study design, data collection, data analysis, and manuscript writing. Hulin Liu contributed to study supervision, conceptualization, and manuscript revision. All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eWe sincerely thank all participants for their generous support and participation in this study.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Innovation Project of Henan High-Performance Medical Device Innovation Consortium (Project number: TR-2025-01-023).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available to protect the privacy and confidentiality of participants. De-identified data are available from the corresponding author on reasonable request. The English version of the interview guide is provided as supplementary material.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFilho AM, Laversanne M, Ferlay J, Colombet M, Pi\u0026ntilde;eros M, Znaor A, Parkin DM, Soerjomataram I, Bray F: \u003cstrong\u003eThe GLOBOCAN 2022 cancer estimates: Data sources, methods, and a snapshot of the cancer burden worldwide\u003c/strong\u003e. \u003cem\u003eINT J CANCER\u003c/em\u003e 2025, \u003cstrong\u003e156\u003c/strong\u003e(7):1336-1346.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003e[Chinese consensus guidelines for breast cancer in young women: clinical practice and fertility preservation]\u003c/strong\u003e. \u003cem\u003eZhonghua Zhong Liu Za Zhi\u003c/em\u003e 2019, \u003cstrong\u003e41\u003c/strong\u003e(7):486-495.\u003c/li\u003e\n\u003cli\u003eZhang S, Guclu SB, Lipsyc-Sharf M, Kapoor NS: \u003cstrong\u003ePregnancy and breast cancer in young women: current updates and future directions\u003c/strong\u003e. \u003cem\u003eTHER ADV MED ONCOL\u003c/em\u003e 2025, \u003cstrong\u003e17\u003c/strong\u003e:22814709.\u003c/li\u003e\n\u003cli\u003eEsserman LJ, Fiscalini AS, Naeim A, Van\u0026apos;T VL, Kaster A, Scheuner MT, LaCroix AZ, Borowsky AD, Anton-Culver H, Olopade OI\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eRisk-Based vs Annual Breast Cancer Screening: The WISDOM Randomized Clinical Trial\u003c/strong\u003e. \u003cem\u003eJAMA-J AM MED ASSOC\u003c/em\u003e 2026, \u003cstrong\u003e335\u003c/strong\u003e(9):763-774.\u003c/li\u003e\n\u003cli\u003eSlamat R, Bracke P, Ceuterick M: \u003cstrong\u003e\u0026quot;Mother in the making\u0026quot;: Motherhood performativity of childless women in rural Pakistan\u003c/strong\u003e. \u003cem\u003ePLOS ONE\u003c/em\u003e 2026, \u003cstrong\u003e21\u003c/strong\u003e(2):e326698.\u003c/li\u003e\n\u003cli\u003eHu L, Xu B, Chau PH, Lok K, Kwok J, Choi E, Lau Y: \u003cstrong\u003eReproductive Concerns Among Young Adult Women With Breast Cancer: A Systematic Review and Meta-Analysis\u003c/strong\u003e. \u003cem\u003ePSYCHO-ONCOLOGY\u003c/em\u003e 2024, \u003cstrong\u003e33\u003c/strong\u003e(8):e9304.\u003c/li\u003e\n\u003cli\u003eWang Z, Yang X, Hong X, He Y, Xu A, Jiang X, Wei Q: \u003cstrong\u003eA Qualitative Study of Fertility Preservation Experience in Women with Breast Cancer\u003c/strong\u003e. \u003cem\u003eINT J WOMENS HEALTH\u003c/em\u003e 2025, \u003cstrong\u003e17\u003c/strong\u003e:1143-1155.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eGlobal burden of 292 causes of death in 204 countries and territories and 660 subnational locations, 1990-2023: a systematic analysis for the Global Burden of Disease Study 2023\u003c/strong\u003e. \u003cem\u003eLANCET\u003c/em\u003e 2025, \u003cstrong\u003e406\u003c/strong\u003e(10513):1811-1872.\u003c/li\u003e\n\u003cli\u003eQiu J, Tang L, Li P, Fu J: \u003cstrong\u003eAn investigation into the reproductive concerns of young women with breast cancer\u003c/strong\u003e. \u003cem\u003eASIA-PAC J ONCOL NUR\u003c/em\u003e 2022, \u003cstrong\u003e9\u003c/strong\u003e(6):100055.\u003c/li\u003e\n\u003cli\u003eZhang Q, Gao W, Li X, Wang D, Zhang L, Xu M, Liu Y, Han J: \u003cstrong\u003eMotherhood role concerns in young women with breast cancer: a mixed-methods study\u003c/strong\u003e. \u003cem\u003eBMC WOMENS HEALTH\u003c/em\u003e 2025, \u003cstrong\u003e25\u003c/strong\u003e(1):313.\u003c/li\u003e\n\u003cli\u003eCuthbertson LM, Robb YA, Blair S: \u003cstrong\u003eTheory and application of research principles and philosophical underpinning for a study utilising interpretative phenomenological analysis\u003c/strong\u003e. \u003cem\u003eRADIOGRAPHY\u003c/em\u003e 2020, \u003cstrong\u003e26\u003c/strong\u003e(2):e94-e102.\u003c/li\u003e\n\u003cli\u003eWheeler SC, Bechler CJ: \u003cstrong\u003eObjects and self-identity\u003c/strong\u003e. \u003cem\u003eCURR OPIN PSYCHOL\u003c/em\u003e 2021, \u003cstrong\u003e39\u003c/strong\u003e:6-11.\u003c/li\u003e\n\u003cli\u003eGraneheim UH, Lundman B: \u003cstrong\u003eQualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness\u003c/strong\u003e. \u003cem\u003eNURS EDUC TODAY\u003c/em\u003e 2004, \u003cstrong\u003e24\u003c/strong\u003e(2):105-112.\u003c/li\u003e\n\u003cli\u003eGraneheim UH, Lindgren BM, Lundman B: \u003cstrong\u003eMethodological challenges in qualitative content analysis: A discussion paper\u003c/strong\u003e. \u003cem\u003eNURS EDUC TODAY\u003c/em\u003e 2017, \u003cstrong\u003e56\u003c/strong\u003e:29-34.\u003c/li\u003e\n\u003cli\u003eOlmos-Vega FM, Stalmeijer RE, Varpio L, Kahlke R: \u003cstrong\u003eA practical guide to reflexivity in qualitative research: AMEE Guide No. 149\u003c/strong\u003e. \u003cem\u003eMED TEACH\u003c/em\u003e 2022:1-11.\u003c/li\u003e\n\u003cli\u003eGreaney ML, Sprunck-Harrild K, Ruddy KJ, Ligibel J, Barry WT, Baker E, Meyer M, Emmons KM, Partridge AH: \u003cstrong\u003eStudy protocol for Young \u0026amp; Strong: a cluster randomized design to increase attention to unique issues faced by young women with newly diagnosed breast cancer\u003c/strong\u003e. \u003cem\u003eBMC PUBLIC HEALTH\u003c/em\u003e 2015, \u003cstrong\u003e15\u003c/strong\u003e:37.\u003c/li\u003e\n\u003cli\u003ePartridge AH, Ruddy KJ: \u003cstrong\u003eFertility and adjuvant treatment in young women with breast cancer\u003c/strong\u003e. \u003cem\u003eBREAST\u003c/em\u003e 2007, \u003cstrong\u003e16 Suppl 2\u003c/strong\u003e:S175-S181.\u003c/li\u003e\n\u003cli\u003eMordenfeld KN, Partridge AH, Sella T: \u003cstrong\u003ePregnancy after breast cancer: latest evidence and practical considerations\u003c/strong\u003e. \u003cem\u003eTHER ADV MED ONCOL\u003c/em\u003e 2025, \u003cstrong\u003e17\u003c/strong\u003e:22791384.\u003c/li\u003e\n\u003cli\u003eLi SS, Zhou ZT, Cheng L, Du WN, Pan ZQ, Zhang J: \u003cstrong\u003eThe Mediating Effect of Psychological Resilience and Coping Style on Fear of Recurrence and Reproductive Concerns in Breast Cancer Patients of Childbearing Age\u003c/strong\u003e. \u003cem\u003ePSYCHOL RES BEHAV MA\u003c/em\u003e 2024, \u003cstrong\u003e17\u003c/strong\u003e:3395-3403.\u003c/li\u003e\n\u003cli\u003eHu L, Xu B, Chau PH, Choi E: \u003cstrong\u003eReproductive concerns among young adult women with breast cancer: a systematic review protocol\u003c/strong\u003e. \u003cem\u003eBMJ OPEN\u003c/em\u003e 2023, \u003cstrong\u003e13\u003c/strong\u003e(7):e71160.\u003c/li\u003e\n\u003cli\u003eLiu C, Liu C, Gao H, Yu X, Chen C, Lin H, Qiu L, Chen L, Tian H: \u003cstrong\u003eMediation Effects of Coping Styles on Fear of Progression and Reproductive Concerns in Breast Cancer Patients of Reproductive Age\u003c/strong\u003e. \u003cem\u003eASIAN NURS RES\u003c/em\u003e 2023, \u003cstrong\u003e17\u003c/strong\u003e(5):245-252.\u003c/li\u003e\n\u003cli\u003eDos SR, Neves ET, Carnevale F: \u003cstrong\u003eQualitative methodologies in health research: interpretive referential of Patricia Benner\u003c/strong\u003e. \u003cem\u003eREV BRAS ENFERM\u003c/em\u003e 2016, \u003cstrong\u003e69\u003c/strong\u003e(1):178-182.\u003c/li\u003e\n\u003cli\u003eMitchell LL, Lodi-Smith J, Baranski EN, Whitbourne SK: \u003cstrong\u003eImplications of identity resolution in emerging adulthood for intimacy, generativity, and integrity across the adult lifespan\u003c/strong\u003e. \u003cem\u003ePSYCHOL AGING\u003c/em\u003e 2021, \u003cstrong\u003e36\u003c/strong\u003e(5):545-556.\u003c/li\u003e\n\u003cli\u003eYao H, Chan C, Chan C: \u003cstrong\u003eChildbearing importance: A qualitative study of women with infertility in China\u003c/strong\u003e. \u003cem\u003eRES NURS HEALTH\u003c/em\u003e 2018, \u003cstrong\u003e41\u003c/strong\u003e(1):69-77.\u003c/li\u003e\n\u003cli\u003eCarr AL, Roberts S, Bonnell LN, Kolva E: \u003cstrong\u003eExistential distress and meaning making among female breast cancer patients with cancer-related fertility concerns\u003c/strong\u003e. \u003cem\u003ePALLIAT SUPPORT CARE\u003c/em\u003e 2023, \u003cstrong\u003e21\u003c/strong\u003e(2):196-204.\u003c/li\u003e\n\u003cli\u003eFacchin F, Buggio L, Dridi D, Vercellini P: \u003cstrong\u003eA woman\u0026apos;s worth: The psychological impact of beliefs about motherhood, female identity, and infertility on childless women with endometriosis\u003c/strong\u003e. \u003cem\u003eJ HEALTH PSYCHOL\u003c/em\u003e 2021, \u003cstrong\u003e26\u003c/strong\u003e(7):1026-1034.\u003c/li\u003e\n\u003cli\u003eHammersen F, Pursche T, Fischer D, Katalinic A, Waldmann A: \u003cstrong\u003ePsychosocial and family-centered support among breast cancer patients with dependent children\u003c/strong\u003e. \u003cem\u003ePSYCHO-ONCOLOGY\u003c/em\u003e 2021, \u003cstrong\u003e30\u003c/strong\u003e(3):361-368.\u003c/li\u003e\n\u003cli\u003eXiao Y, Gu C, Liu L, Zeng X: \u003cstrong\u003eRelationships among fertility concerns, fear of cancer recurrence, social support, self-efficacy, and family resilience among Chinese adolescents and young adults with cancer: A structural equation modeling\u003c/strong\u003e. \u003cem\u003ePLOS ONE\u003c/em\u003e 2026, \u003cstrong\u003e21\u003c/strong\u003e(2):e341351.\u003c/li\u003e\n\u003cli\u003eVesztergom D, N\u0026aacute;n\u0026aacute;ssy L, Polg\u0026aacute;r C, Kr\u0026aacute;di A, Rosta V, Varga S, Nov\u0026aacute;k Z: \u003cstrong\u003e[Fertility preservation in female cancer patients.]\u003c/strong\u003e. \u003cem\u003eORVOSI HETILAP\u003c/em\u003e 2023, \u003cstrong\u003e164\u003c/strong\u003e(28):1094-1101.\u003c/li\u003e\n\u003cli\u003eBenedict C, Hahn AL, McCready A, Kelvin JF, Diefenbach M, Ford JS: \u003cstrong\u003eToward a theoretical understanding of young female cancer survivors\u0026apos; decision-making about family-building post-treatment\u003c/strong\u003e. \u003cem\u003eSUPPORT CARE CANCER\u003c/em\u003e 2020, \u003cstrong\u003e28\u003c/strong\u003e(10):4857-4867.\u003c/li\u003e\n\u003cli\u003eCampbell-Enns H, Woodgate aR: \u003cstrong\u003eThe psychosocial experiences of women with breast cancer across the lifespan: a systematic review protocol\u003c/strong\u003e. \u003cem\u003eJBI Database System Rev Implement Rep\u003c/em\u003e 2015, \u003cstrong\u003e13\u003c/strong\u003e(1):112-121.\u003c/li\u003e\n\u003cli\u003eClur LS, Barnard A: \u003cstrong\u003eReconstructing a Meaningful Self: The Identity Work of People Living With Chronic Disease\u003c/strong\u003e. \u003cem\u003eQUAL HEALTH RES\u003c/em\u003e 2025, \u003cstrong\u003e35\u003c/strong\u003e(13):1410-1422.\u003c/li\u003e\n\u003cli\u003eHuang S, Huang M, Long F, Wang F: \u003cstrong\u003ePost-traumatic growth experience of breast cancer patients: A qualitative systematic review and meta-synthesis\u003c/strong\u003e. \u003cem\u003ePLOS ONE\u003c/em\u003e 2025, \u003cstrong\u003e20\u003c/strong\u003e(1):e316108.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":false,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Breast cancer, Fertility distress, Female identity, Identity reconstruction, Reproductive-age women, Qualitative study","lastPublishedDoi":"10.21203/rs.3.rs-9443174/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9443174/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eBreast cancer is common among reproductive-age women in China. Treatment may impair fertility and cause fertility-related distress, which is closely associated with female identity. However, in-depth qualitative studies remain scarce.\u003c/p\u003e\u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eTo explore the experiences of fertility-related distress, its relationship with female identity changes, coping dilemmas, and pathways of identity reconstruction among reproductive-age women with breast cancer in China.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative study based on interpretative phenomenology and self-identity theory was conducted. Semi-structured in-depth interviews were performed with 25 participants. Data were analyzed using Graneheim and Lundman\u0026rsquo;s qualitative content analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFour themes were identified: (1) multidimensional fertility-related distress; (2) a vicious cycle between distress and negative identity changes; (3) multifaceted coping dilemmas; and (4) a progressive pathway of identity reconstruction including expectation adjustment, self-value remodeling, post-traumatic growth, and multidisciplinary support.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eFertility-related distress is culturally specific and closely tied to female identity, forming a vicious circle. A multidisciplinary support model is needed to alleviate distress and promote identity reconstruction to improve quality of life.\u003c/p\u003e","manuscriptTitle":"Fertility-related distress and female identity reconstruction among reproductive-age women with breast cancer in China: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-15 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