The decision-making pathway and enablers to the utilization of assisted reproductive technology in Lagos metropolis: an interpretive phenomenological study

A phenomenological research design was used in this study. As a research design, “it seeks to describe the essence of a phenomenon by exploring it from the perspective of those who have experienced it” [ 21 ]. This design also helps researchers to “understand people’s perceptions, perspectives and understanding of a particular phenomenon” [ 22 ]. The social experiences of infertile and childless women were explored in this study. Within their given social context and reality, the phenomenological research design was used to explore the experiences of infertile women without the researchers imposing preconceived notions, knowledge, theories or interpretations of their social experiences. Alfred Schutz’s phenomenology theory was used in this study [ 23 ]. This theoretical approach allowed us to conceptualize each participant’s experiences based on their respective social world. The individual’s experiences constitute a given social phenomenon as these individuals’ social worlds are reconstructed by their personal experiences. As a result, the design allowed for greater comprehension of the decision-making pathway in the use of ARTs and enablers of using these services from the participants’ social context. Furthermore, based on the phenomenological theory of Alfred Schutz as applied in this study, we were able to conceptualise each participants experiences based on the respective social world experiences which put together provides insight into the general social world of infertile and childless couples. Within the context of this study, their collective experiences is a “typification” (which is a classes of things that are experienced) by each individual couple, but shared by all of them because their experiences makes them see the social world in the same way. Phenomenology remains “a powerful research strategy that is well suited for exploring challenging problems” [ 24 ] being experienced by members of the society. This work was conducted in a support group; this private support group provides men and women going through infertility a safe place to live through the challenges of infertility. It provides referral services and atmosphere to share experiences with others going through similar life events. Coping strategies are also shared, which provide an additional resource. In addition, support groups are established in ART clinics within Lagos state. Support groups for couples undergoing ART services are considered an important social network. This is because the support groups also provide health literacy, health information and counselling services. Some of these support groups assist couples through their difficult time by providing counselling services and refer them to established psychiatric counsellors if the need arises. The private support group at the ART clinics used in this study has been in operation for more than 10 years in Lagos State. The state is considered the centre for business and commerce in Nigeria. Lagos State is located on the southwestern part of Nigeria and is bounded on the north by Ogun state, in the west by the neighbouring Republic of Benin and south by the Atlantic Ocean. The state is inhabited by people from diverse ethnic groups. The area of Lagos consists of two regions: the Island, which is the origin city and the mainland, which is made up of growing settlements. The climate in Lagos is tropical, hot and cold. The environment is characterised as coastal, with wetlands, sandy barrier islands, beaches, low living tidal flats and estuaries. The average temperature in Lagos is 270 C and the annual average rainfall 1533 mm. Presently the seat of government is located in Alausa within Ikeja which is the capital of Lagos state. Women registered in support groups at a Fertility Clinic in Lagos State, Nigeria. These women are of reproductive age but are unable to get pregnant. Some of these women have a long menstrual cycle, with intervals of 35 days or more. While others have a menstrual cycle that is too short, being less than 21 days, leading to irregular or the absence of ovulation. Despite having a uterus, these women are unable to get pregnant. Women who had sought ART services by the time of the study were purposively recruited to provide insights on their experiences related to the study’s objectives. This was done by sending a notice of the research to the support group chat page on WhatsApp. Those who desired to be part of the study and consented (confirmed when they returned responses privately to the lead support group coordinator) to participate in it. No direct contact was allowed by the researchers) onto the WhatsApp group. That is, these women reached out to the Administrator privately and were thereafter sent the open-ended semi-structured instrument which they filled accordingly and returned to her private WhatsApp phone line. An open-ended semi-structured interview guide was developed to capture responses on the decision-making pathway and enablers in the use of ARTs. The interview guide was developed from reading of existing literature on the subject-matter. The guide was divided into three sections. Section one was on the socio-demographic characteristics of the women, section two was on the deciding factors that influenced the women to make use of ART, and section three was on the enabling factors. That is, the interview guide was designed to collect data on participants ‘personal data and clinical characteristics’ and a description of their decision pathways to use and enablers that motivated the eventual use of ARTs. The interview guide had ten questions to elicit the responses of the women. The interview guide was reviewed by two of the authors AUC (Asiegbu Ugochinyere Chizurumuoke) and ASO (Ajike Saratu Omagbemi), and was thereafter pilot-tested before its use in the study. The pilot study took place in a fertility clinic in Sagamu. The complete data collection took two weeks. The participants were asked various questions which included the following: why did you decide to utilize assisted reproductive technologies?, what factors enabled your decision to utilize assisted reproductive technologies?, Can you describe your experience with trying to conceive? For how long have you been trying to conceive? All responses were collated and returned via email. These were downloaded to a password-protected personal computer. The data were analyzed manually using the procedures stated by [ 25 , 26 ]. After the data were collected, they were read three times by each team member to get a sense of the general flow of experiences. By the fourth reading, the transcriptions were then read again purposefully to assign codes which began with the first transcript. This was then used to code other transcripts accordingly, beginning with a key code and its sub themes until all transcripts were read and an agreement was reached by all authors on saturation. Furthermore, the data derived from the interviews of the participants was analysed in line with the study objectives. The process started first with the data been downloaded and then transcribed without distorting the language. Afterwards, a thematic content analysis was used to break down the data into major themes and sub-themes. The codes and sub-codes were derived from reading through the transcripts. The definition of each sub-code linked with the codes, sub-themes and major theme was written out to provide a clear understanding of what it means. The analysis process provides a clear descriptive insight into the nature of the data. A coding scheme (codebook) was developed to data analysis. The codes developed were harmonised to ensure consistency before it is applied to the data. This process is what [ 27 ] described to discern patterns and relationships among themes. The two major themes that emerge from the data were discussed among the researchers. During the process of data analysis, inter-coder reliability also known as inter-coder agreement/inter-rater reliability [ 28 , 29 ] was employed as two independent coders went through the transcripts. Trustworthiness was achieved; first through dependability where the researchers attempted to provide a clear coding description of the analysis using coding schemes to allow repetition. In addition, a detailed description of the methodological processes has been aforementioned including a clear description of the study setting and provision of responses without altering the language construct/tense. The dependability of the study shows that the process is logical, traceable and clearly documented [ 30 ]. Secondly, through credibility the findings of the study were discussed among team members until an agreement was reached on consistency of findings. Although, the authors attempted to achieve further credibility through respondent checks, however this could not be achieved, since researchers were not allowed direct contact with the respondents even after all efforts were made to bridge that gap. While in terms of transferability, the researchers have provided a thick description of the study and clear explanation from the findings [ 31 ]. The study findings are all based on the data collected which formed the interpretations and conclusions derived. This explains the confirmability of this study [ 31 ]. More so, this study’s data was obtained based on good listening during the process of interviewing the participants. Good listening is a major criterion of trustworthiness in qualitative research [ 32 ].

The participant’s mean age was 32.72 ± 5.33 years. Half of the participants (50%) was of Igbo ethnic group. All of them (100%) had BSc educational qualifications and were married. More than half of the participants (66.7%) had a formal employment status. Most of them 16 (88.9%) had primary infertility and 10 (55.6%) had three or more treatment attempts. (Table  1 ). Table 1 Socio-demographic Characteristics of the Respondents ( N =18) Socio-demographic characteristics N (%) Age 18-25 1(5.60) 26-33 11(61.30) 34-41 5(27.95) 42-49 1(5.60) Ethnicity Igbo 9(50.0) Yoruba 4(22.20) Hausa 5(27.80) Others 0(0.00) Employment status No employment 0(0.00) Formal employment 12(66.70) Informal employment 6(33.30) Marital status Single 0(0.00) Married 18(100) Divorced 0(0.00) Educational status No education 0(0.00) Primary 0(0.00) Secondary 0(0.00) Tertiary 18(100.0) Duration of infertility Primary 16(88.9) Secondary 2(11.10) Number of attempts 1 6(33.3) 2 2(11.10) 3 10(55.6) Socio-demographic Characteristics of the Respondents ( N =18) Two themes- the decision to use ARTs and enablers with sub-themes are outlined below (Table  2 ). Table 2 Themes and Sub-themes Themes Sub-themes The decision to use ARTs Personal Inter-personal Relational Enablers to use ARTs Social support (Emotional, Informational, and Appraisal Inter-personal influences (social pressure, expectations, healthy role models) Information about underlying illness requiring use of ART Professional recommendation Lay suggestion Themes and Sub-themes This theme was used to depict the personal, interpersonal, and relational (mutual elements) in the pathway of decisions taken by the participants to use ARTs. The personal as a sub-theme described different things from the person’s perspective that led to the participant’s decision to use ART, the inter-personal explained the roles people played in the pathway of the decision to use ART and the relational defined the involvement of spouses and immediate family members in the participant’s decision that led to the use of ART. Furthermore, this sub-theme described different things that led to the participant’s decision to utilize ART. From the varying experiences, it is evident that the participants’ decisions were based on desires to become a mother which is seen as an achievement and will change their dynamics forever. Some participants expressed having a child of their own as a yardstick for their decisions to experience the pregnancy-related symptoms and gain confidence in women gathering. Most of the participants referred to their health condition which includes; Polycystic Ovarian Syndrome, Fibroids, Endometriosis, blocked and beaded fallopian tubes which they were diagnosed of before or after married and had prevented them from achieving a natural pregnancy after so many years of trials, they also expressed how they underwent series of surgeries, treatments and frequent visitations to the hospitals and clinics. In addition, participants also highlighted aging and feelings of restlessness and inadequacies which became part of their everyday thought and led them to depression, anger and sadness as triggers to their decisions to utilize Assisted Fertility Techniques. Some participants described how they were restless and felt inadequate about their situation most of the time. The feeling of not having a child after several years of marriage and failed treatment attempts rekindled their quest for a child and resilience to use ARTs. This is stated below as: “I told myself that one more push had every virtue. I decided to embark on this journey once more , especially considering the availability of frozen eggs. I was given a mild prescription for this seventh trial because there were eggs available”. (Participant , A) “I started my third cycle of resiliency that was fueled by prayers. I wouldn’t give up on my goal of being a mother”. (Participant , A) “I told myself that one more push had every virtue. I decided to embark on this journey once more , especially considering the availability of frozen eggs. I was given a mild prescription for this seventh trial because there were eggs available”. (Participant , A) “I started my third cycle of resiliency that was fueled by prayers. I wouldn’t give up on my goal of being a mother”. (Participant , A) Another participant expressed that; “As soon as I learned about IVF treatment , I embarked on it because I was growing restless with my emotions of inadequacy and helplessness”. (Participant , B)“My first IVF attempt , at age 20 , was unsuccessful. I never gave up since I was desperate to start a family”. (Participant , D) “As soon as I learned about IVF treatment , I embarked on it because I was growing restless with my emotions of inadequacy and helplessness”. (Participant , B)“My first IVF attempt , at age 20 , was unsuccessful. I never gave up since I was desperate to start a family”. (Participant , D) Some of the participants explained how their inability to birth a child was the problem and they were determined to become a parent, while others were proud of their personal qualities and pictured themselves as wonderful mothers. Such is expressed below as: “Even though I was aware of how poor my odds were , I wasn’t going to let that stop me from pursuing my desire to become a parent”. (Participant , F) “Even though I was aware of how poor my odds were , I wasn’t going to let that stop me from pursuing my desire to become a parent”. (Participant , F) Another participant affirmed that: “I was certain that I wanted to have children and that I would be a wonderful mother”. (Participant , L) “I was certain that I wanted to have children and that I would be a wonderful mother”. (Participant , L) This sub-theme explains the roles people played in the pathway of the decision to use ART. The family members of some of the participants who had used ARTs in the past served as role models to the participants which helped them to decide to use ARTs and give a second chance. Some participants also stated that their friends who have used ARTs helped them in taking the bold step to use ARTs-these friends referred them to qualified professionals and registered fertility clinics with different ART options. Participants shared how the experiences of family members, siblings, and friends with ARTs buttressed their decision to use it. Because friends, family members and a person’s siblings contribute to people’s daily lives across the world, the same is experienced by infertile couples. Their friend network provided a source of support for many of them and this guided their decision making to use ART. This is stated as follows: “My husband and I decided to ask our family members , friends and siblings who have used ARTs about their experiences and what they said helped in building our faith to use ARTs”. (Participant , P) “My husband and I decided to ask our family members , friends and siblings who have used ARTs about their experiences and what they said helped in building our faith to use ARTs”. (Participant , P) This sub-theme was defined as the involvement of spouses, immediate family members in the participant’s decision that led to the use of ART. Most of the participants had mentioned their spouses’ agreement with their intentions to use ARTs for assisted conception, they stated how their partners had to give their consent before they proceeded with their decisions to use ART. Their consent was important to them as their sperm were required for the treatment processes. Few participants attributed it to their spouses’ desire to become a parent, they explained the roles played by their partners throughout their conception journey and how they also visited the clinics for treatments and other consultations. However, almost half described their spouse’s aspirations for another child as a contributor to their decision to utilize ARTs; they perceived that they needed to expand their family. Participants described their spouses’ eagerness to give their first child another sibling; they were of the opinion that their child was lonely and in need of another sibling. Furthermore, some participants explained that the health conditions such as low sperm count, certain genetic diseases of their spouses strengthened their decision to utilize ART. Most Participants explained how they made a joint decision with their spouse and went about all their treatments together. Joint-decision making is an important practice in marriage. As such, for infertile couples, being able to make the decision together is instrumental to strengthen their marital relationship. Participants expressed their views as: “My husband and I decided to seek medical attention after six years of bedroom struggles. We began our adventure at the Lagos University Teaching Hospital (LUTH) where we underwent clinical testing and inspections”. (Participant , A) “My husband and I decided to seek medical attention after six years of bedroom struggles. We began our adventure at the Lagos University Teaching Hospital (LUTH) where we underwent clinical testing and inspections”. (Participant , A) Another participant recalled that: “We started trying to get pregnant , but it never worked out. Without wasting any time , my husband and I headed to a reproductive clinic”. (Participant , D) “We started trying to get pregnant , but it never worked out. Without wasting any time , my husband and I headed to a reproductive clinic”. (Participant , D) A different Participant described her experience thus: “I recognized something was wrong with me , we tried for five years to give our child a sibling and when nothing was happening , we decided to use IVF”. (Participant , G)“So , after a year of not conceiving , we decided to seek fertility treatment because we had plans to expand our family”. (Participant , O) “I recognized something was wrong with me , we tried for five years to give our child a sibling and when nothing was happening , we decided to use IVF”. (Participant , G)“So , after a year of not conceiving , we decided to seek fertility treatment because we had plans to expand our family”. (Participant , O) Participants were of the view that emotional support received from their mothers while trying to conceive facilitated the use of ARTs. This support was received after several treatments and failed attempts which helped to boost their confidence and improve their disposition. Few participants expressed how their husband’s support motivated them to use ARTs despite their health conditions which stood as an obstacle in their struggle to have children and they also mentioned the sacrifices they made to ensure that their treatment was successful such as reducing the consumption of alcohol and providing all requirements for speedy recovery after the treatment. Few participants described using ARTs as a result of the emotional support and appraisals received from a group which included women with similar experiences, who made it easier for them to rub minds, pray and indulge in several coping strategies. Also, a participant said that the testimonies shared by women who have used ARTs for assisted conception aided her to use ARTs for assisted conception. Again, it was mentioned by a participant that the information she received concerning the clinics to use for ARTs was based on referral from people who had used a particular clinic for this purpose, she explained how it gave her the assurance she needed to proceed with her ARTs adventure. Participants recalled how their husband’s advice not to give up, their mother’s consolation after failed attempts, and involvement in a group motivated her to use ART. That is, social support from family members and their social networks further reinforced their decision to use ART. A participant said that: “My husband’s advice to never give up was something I clung to. I thus tried one more”. (Participant , C) “My husband’s advice to never give up was something I clung to. I thus tried one more”. (Participant , C) Another participant explained that: “I confided in my mother and I started my third cycle of resiliency that was fueled by prayers. I wouldn’t give up on my goal of being a mother”. (Participant , A) “I confided in my mother and I started my third cycle of resiliency that was fueled by prayers. I wouldn’t give up on my goal of being a mother”. (Participant , A) A different participant mentioned that: “ My big sister introduced me to a group where we had other people going through what I was going through. It became a bit easier rubbing minds with these sisters , we encourage ourselves together and nobody is left behind , advising each other , clocking in of smoothies , praying together and spicing up our marriage”. (Participant , Q) “ My big sister introduced me to a group where we had other people going through what I was going through. It became a bit easier rubbing minds with these sisters , we encourage ourselves together and nobody is left behind , advising each other , clocking in of smoothies , praying together and spicing up our marriage”. (Participant , Q) This sub-theme has been described to mean informational elements related to existing ailments of the woman or spouse and other information which prompted the need for ART These health conditions comprised Polycystic Ovarian Syndrome, Fibroids, Endometriosis, Infertile eggs, excess testosterone, blocked and beaded fallopian tubes, obstructed fallopian tubes and tubal blockage which were diagnosed prior to the use of ARTs. Most of the participants expressed how they felt when they learnt about their health status and the treatments/surgeries slated for them to do. Also, some of them did not hide the fact that these surgeries/ treatments made them bankrupt while others had to seek financial assistance from family members and friends. In addition, some participants revealed that their spouses’ health conditions such as low sperm count which was diagnosed after a series of tests at the clinic left them with only one option- which was ARTs. In addition, a participant did not forget to disclose how she was informed about her age being a barrier and the poor odds for natural births. According to her, this news made her sad for a very long time and when she sought for a way forward, she had to settle for ARTs. Again, a participant revealed how she relied on the scriptures in the bible for strength to continue her ARTs trials after numerous failed attempts or miscarriages. Some participants appreciated those who gave them relevant information; positive disposition from their parents, awaiting a positive result from natural birth engineered them to use ART. This type of information was useful to the participant. This is stated below as: “Returning to conventional medicine… At the time , we were receiving treatment at the Ghana police hospital from a specialist , which was strongly recommended by several people”. (Participant , I) “Returning to conventional medicine… At the time , we were receiving treatment at the Ghana police hospital from a specialist , which was strongly recommended by several people”. (Participant , I) One of the participants described how the testimonies of women helped to build her faith in IVF. This she expressed as: “I have been following testimonies of women who were not Nigerians online who had similar issues as mine because most Nigerian women do not like to talk about issues like this , their testimonies helped to build my faith and hope so I decided not to give up”. (Participant , R) “I have been following testimonies of women who were not Nigerians online who had similar issues as mine because most Nigerian women do not like to talk about issues like this , their testimonies helped to build my faith and hope so I decided not to give up”. (Participant , R) This sub-theme explained the social pressure in the form of nuances in people’s statements and behavior experienced by participants which brought about the evidence of their unfolding realities and as such led to seeking for medical assistance. Another participant mentioned their sister-in-law’s efforts to ensure they conceived by bringing different concoctions for them to take and advising them to drink alcohol as it has the potential to aid immediate conception. Also, a participant described how the pregnancy announcements made by spouses during church services got her pressured and she could count the number of times she slept during that period so she was left with no other choice than to act immediately which led to the use of ARTs. In addition, a participant disclosed how the cumbersome expectations of more grandchildren from her mother-in-law after the first and second successful pregnancies and deliveries facilitated her third, fourth and fifth ARTs journeys. Furthermore, a participant had explained how her mother’s friend who had used ARTs for assisted conception in the past and had a positive result accompanied with pregnancy and delivery (though the baby was preterm), stood as a role model which engineered her to opt for ARTs while another referred to how she thought she had all that she needed in life until she witnessed how happy people who had children were and that burning desire to be like them arose. Moreover, a participant expressed how sad and depressed she became after hearing the words people said to her such as “why don’t you have a baby?” “When are you going to have a baby?,” broke her heart and as a result led to deep meditation and the use of ART. Participants described how her mother-in-law’s words, statements, and behaviors of people, and hurtful words from people ended their productive break and they opted for ART. A participant stated as follows: “A few years later , when my mother-in-law came visiting , she noticed the kids playing. She was open about her desires. Don’t ever think I don’t want more grandchildren , she warned me. My productive break was over with that one sentence. Once more , I went for it. Twins were born following the third round of reproductive treatment”. (Participant , B) “A few years later , when my mother-in-law came visiting , she noticed the kids playing. She was open about her desires. Don’t ever think I don’t want more grandchildren , she warned me. My productive break was over with that one sentence. Once more , I went for it. Twins were born following the third round of reproductive treatment”. (Participant , B) Another participant stated that: “When I started to observe nuances in people’s statements and behaviors , my unfolding realities became evident”. (Participant , A) “When I started to observe nuances in people’s statements and behaviors , my unfolding realities became evident”. (Participant , A) Some other participant disclosed that: “I’ve always thought that IVF babies are never healthy. My mother’s friend used in vitro fertilization (IVF) , but the child was born prematurely , this made me consider IVF”. (Participant , D) “I’ve always thought that IVF babies are never healthy. My mother’s friend used in vitro fertilization (IVF) , but the child was born prematurely , this made me consider IVF”. (Participant , D) A different participant added that: “As the years passed , everyone around me seemed to be happier and had children”. (Participant , E) “As the years passed , everyone around me seemed to be happier and had children”. (Participant , E) While another participant mentioned that: “ No positive test results in the first month. No positive test was found in the second month. Around the same time , spouses started making pregnancy announcements. Each month I cried”. (Participant , L) “ No positive test results in the first month. No positive test was found in the second month. Around the same time , spouses started making pregnancy announcements. Each month I cried”. (Participant , L) Another participant went on to describe the influence of some people which were expressed in ways that made them to be hurt. A participant stated that: “It is not just a loss of a baby but the loss of a dream , words people said to me broke my heart such as why don’t you want to have a baby? When are you going to have a baby? it was a difficult decision”. (Participant , N) “It is not just a loss of a baby but the loss of a dream , words people said to me broke my heart such as why don’t you want to have a baby? When are you going to have a baby? it was a difficult decision”. (Participant , N) Participants expressed how they felt sad when they heard that they were ill and their partners were ill as well. That is, certain types of illness that were discovered in their bodies, forced them to opt for ART. A participant disclosed that: “ There , the doctor informed us that he had a condition called non-motile per slide , which refers to a lack of active sperm cells in his semen. My husband’s semen was frozen at that time so that viable sperm cells could be harvested as we started a new cycle”. (Participant , D) “ There , the doctor informed us that he had a condition called non-motile per slide , which refers to a lack of active sperm cells in his semen. My husband’s semen was frozen at that time so that viable sperm cells could be harvested as we started a new cycle”. (Participant , D) One of the participants stated that: “I understood that my eggs are infertile and I will never be able to conceive”. (Participant , E) “I understood that my eggs are infertile and I will never be able to conceive”. (Participant , E) A different participant expressed their views that: “I had never considered using my body for scientific conception since I had spontaneously given birth to my first child. Yet , results showed that my right Fallopian tube was obstructed”. (Participant , G) “I had never considered using my body for scientific conception since I had spontaneously given birth to my first child. Yet , results showed that my right Fallopian tube was obstructed”. (Participant , G) A different participant mentioned that: “My doctor identified PCOS after I got married and had trouble conceiving. I was informed by the fertility clinic we visited that my eggs were infertile; therefore , we had to choose the donor option”. (Participant , H) “My doctor identified PCOS after I got married and had trouble conceiving. I was informed by the fertility clinic we visited that my eggs were infertile; therefore , we had to choose the donor option”. (Participant , H) While another participant explained that: “In 2018 , I underwent laparoscopy and hysteroscopy to examine the inside of the uterus to diagnose further treatment or surgery. During this process , it was revealed that my tubes were blocked and beaded. The fertility doctor suggested IVF”. (Participant , M) “In 2018 , I underwent laparoscopy and hysteroscopy to examine the inside of the uterus to diagnose further treatment or surgery. During this process , it was revealed that my tubes were blocked and beaded. The fertility doctor suggested IVF”. (Participant , M) This sub-theme covered the doctor’s or physician’s recommendation to use ARTs. Participants who made the decision to utilize ARTs testified about how their doctor’s suggestion aided the use of ARTs. They mentioned how their doctors encouraged them to continue with their treatment and trials after so many failed attempts. Some of the participants further disclosed how their physician chose the fertility treatment that was best for them and assisted them until a pregnancy was achieved. Others described the swift response of their doctors to any unusual change in their bodies as a facilitator to continue their treatments till it was successful. Also, participants who were still indecisive about using ARTs revealed that their doctor’s advice to attempt ARTs aided their decision to use ARTs even though it was not cost effective. Participants did not forget to mention how helpful their doctors were to them even after failed attempts. A participant explained that: “We had discussions with my doctor and she recommended some herbs for us to use. After months of taking the herbs and they did not work so the doctor encouraged us to go for IVF but we told her that there was no money”. (Participant , P) “We had discussions with my doctor and she recommended some herbs for us to use. After months of taking the herbs and they did not work so the doctor encouraged us to go for IVF but we told her that there was no money”. (Participant , P) Another participant shared that: “ My doctor identified PCOS after I got married and had trouble conceiving. IVF was suggested to us , but my husband was first hesitant to attempt it. Afterwards , he consented”. (Participant , H) “ My doctor identified PCOS after I got married and had trouble conceiving. IVF was suggested to us , but my husband was first hesitant to attempt it. Afterwards , he consented”. (Participant , H) A different participant mentioned that: “I located a good clinic in my area , registered and started treatment. The first attempt was not successful and the doctors suggested I tried it again; I underwent the second attempt and it was successful”. (Participant , R) “I located a good clinic in my area , registered and started treatment. The first attempt was not successful and the doctors suggested I tried it again; I underwent the second attempt and it was successful”. (Participant , R) This sub-theme concentrated on counsels given by non-professionals. A participant reported being motivated by people living in the neighborhood who shared the idea of using ARTs for assisted conception during one of their random discussions. Also, a participant described how her sister’s proposition to use ARTs also led to its use for assisted conception. Some of the Participants were excited and expressed how their sister and neighbors suggested IVF and encouraged them to use it. Such encouragement mattered to them. One of the Participants disclosed that: “In March 2022 , my sister came to visit me and she suggested IVF and I was hesitant at first”.(Participant , Q) . “In March 2022 , my sister came to visit me and she suggested IVF and I was hesitant at first”.(Participant , Q) . Another participant said that: “At the time , we were receiving treatment at the Ghana police hospital from a specialist , which was strongly recommended by several people”. (Participant , I) “At the time , we were receiving treatment at the Ghana police hospital from a specialist , which was strongly recommended by several people”. (Participant , I)

Around the world and particularly in Africa, where childless couples are seen as incomplete, the inability to have children has become a personal misfortune for them and particularly women [ 1 ]. This societal shame can have major repercussions on the private anguish of childless couples [ 2 ]. In a bid to disengage from these challenges, some infertile persons seek Assisted Reproductive Technology (ART), which involves therapies or procedures that include managing human sperm and eggs in vitro to induce pregnancy and overcome innate barriers to pregnancy [ 3 ]. Globally, ten of every seventy couples experience some form of infertility [ 4 ]. In Africa, infertility affects 15—30% of the population [ 5 ]. Couples who are having trouble conceiving may endure health issues such as weight loss, high blood pressure, anxiety, sadness, and mental illnesses, as well as sometimes even mortality and detrimental health conditions [ 6 ]. However, these infertility-related illnesses are no longer as prevalent because of technological advancements known as Assisted Reproductive Technologies (ARTs). These services, which offer alternative mechanisms for conceptions for these couples, are increasingly being used to aid infertile couples begin conception [ 7 , 8 ]. The introduction of assisted reproductive technologies has led to a reduction in infertility cases of more than 50%, giving couples who previously had no possibility of becoming parents an opportunity to do so [ 9 ]. Despite the successes recorded from ART, sub-Saharan Africa still has the lowest ART adoption rate, with only 71 cycles per million people per year as at the latest report [ 10 ]. Many access barriers to ARTs still exist in Nigeria as well as other countries in Sub-Saharan Africa, and include financial barriers as a directly associated factor [ 11 – 13 ]. Deficient health systems, a number of conflicting health goals, absence of third-party funding plans, far more private ART clinics than public ones, and homes with low purchasing power [ 14 ] including psycho-cognitive barriers such as lack of knowledge and beliefs [ 11 ]are further contributing factors that hinder access to and use of ART services. In Nigeria, equal and fair access to reproductive technology has been and is still problematic, and it is rarely given top priority in public health benefits programs [ 15 , 16 ]. Also, the cost of receiving therapy and establishing this technology in Nigeria where they are most required prevents their widespread use [ 17 ]. The few available studies on ART in Nigeria have focused mainly on the Knowledge, Perception, Attitude, Willingness, and Ethical issues related to the use of ARTs [ 18 – 20 ]. Studies detailing the experiences of the affected are very limited and virtually nonexistent. Thus, we have not been able to subjectively explain and properly document the person-centered perspectives of infertility and health-seeking behaviors among the cohort of women. This study sought to explore the experiences of women who have lived through infertility to understand the decision pathway to using ARTs and what, despite the barriers, motivated them to seek ART services.

Women who have used ART services in this study setting reported varied experiences which affected their well-being. However, these women received different forms of support which enabled them to use ARTs. More so, the various factors which influenced their decision to use ART remain very crucial in guiding women with fertility issues. The use of ARTs has given infertile and childless couples a glimmer of hope and the chance to escape the strain and stigma of childlessness in society. This study recommends that public health professionals collaborate with ART service providers in providing psychosocial care in addition to basic clinical care. Also, the study recommends that clinical and health psychologists have a major role to play in the health care and management of women that make use of ART services. Future studies can explore the perspectives of significant others as they played key important roles in the decision and motivation to use ART. More qualitative studies are also needed to explore the role of friends in framing the decision making process for infertile couples to make use of ART services, while qualitative studies can explore the relevance and value of religious organisations/clerics in providing succor for infertile couples during their challenging times.

This qualitative study was aimed at exploring the decision making pathway in the use of ART and enablers influencing women’s decision to utilize ARTs. Data were analyzed inductively and deductively, and the following themes were derived. Two major themes evolved from the coding process of analyzing the data. These themes are; (1) the decision to use ARTs, with sub-themes of personal, interpersonal, and mutual actors in the decision pathway to use ART, and (2) enablers to use ARTs with sub-themes of social support, appraisal, inter-personal, informational, professional and lay influencers.This study revealed that all participants had made a personal, mutual, or inter-personal decision to use ARTs for assisted conception, and factors such as emotional support from the mother, and spouses, social pressure, information about health conditions, professional suggestions, and lay suggestions enabled their decision to materialize into the eventual use of ART service. Based on the objectives of this study, this study shows that the decision to use ART and the enablers to use ART are very crucial to understanding the social dynamics of women’s health especially when faced with infertility issues. This study show that the age of the participants ranged from 18 to 49 years old. These women find themselves within the childbearing of 15–54 according to the [ 33 ]. In Nigeria studies have shown that the reproductive ages for women that have used ART services [ 34 – 36 ]. As regards the ethnic affiliation of the participants, the study shows a variation. In Nigeria, there are three main ethnic groups and other sub-groups. This study captures this reality based on existing ethnicity grouping in the country. On the employment status, some of the participants are engaged in some form of formal employment. That is they have a job that either runs from 8am to 4pm or from 9am to 5pm. Such formal employment cuts across working in a government establishment or a private organization. In terms of marital status, all of the participants were married as at the time the study was conducted. While for the educational status of the participants, all of them have obtained a tertiary level of education which will mean they all have been to either a university or a polytechnic to obtain a degree or higher national diploma. On the duration of infertility, majority of the participants in this study had primary infertility and a few of them had secondary infertility. The issue of primary infertility has become a major concern for many women of reproductive age in Nigeria [ 37 ]. On the number of attempts participants have had with ART, this varied from between 1 and 3. Hence, Nigerian women that have experienced either primary or secondary infertility, that have opted for the use of ART at least once [ 16 ]. Women who have used ART have had varied yet similar mixed experiences resulting from their inability to conceive, the decisions they made and what the enablers were that motivated them to use ART. Although many of the women decided to use ART on their own, some of them wanted their husbands to be part of the decision-making process, while others were in joint agreement with their husbands. Participants revealed that their decisions originated from their aspirations, feelings of restlessness and inadequacies, desperations, desire to become a parent, and knowledge. While others mentioned that both they and their spouses decided to use ARTs for treatment, and even after several failed attempts did not give up. In Chile, their decisions were more physician-driven. They preferred their doctors to make decisions for them and did not like to be forced, this was because of the trust they have in the physicians and also fear of the consequences that might result from their personal decisions made [ 9 ]. The participants reported that they were sad, depressed, angry, and worried a lot about their situation and were dissatisfied after failed attempts. These psychological manifestations are comparable to those reported in another study [ 38 ], who found that women admitted to worrying about their infertility issue. The majority of the participants in a related study [ 39 ] reported experiencing severe unhappiness and dissatisfaction as a result of their failure to conceive. The participants reported other emotional moments where they cried, yelled, read their Bibles, and meditated to always feel better because of their condition, which assisted them in coping with their unmet expectations. The same strategies were used by the participants in a similar study [ 40 ] to help them deal with their disappointments. Generally, most women experience numerous negative feelings. However, while experiencing these negative feelings, some are able to engage in spiritually positive activities which may aid the journey through the dark. Most of the participants received support from their husbands which helped them during their treatments and after failed attempts. Despite their husbands’ desperation about their circumstances, they continued to treat their marriages with respect. The vast majority of the husbands were praised for being the best, considerate, and encouraging. Because of this, many participants did not feel pressured by their husbands to have a divorce or get remarried, as has been documented in other studies [ 41 , 42 ]. This is one of the reasons that enabled women to use ART. Spousal support remains crucial in the promotion of women’s health and well-being. The findings also revealed that one of the challenges faced by the participants while they used ART was the financial burden associated with it. Funding ART for most of the women required making sacrifices and seeking financial assistance. These results are in line with those of [ 43 ], who found that when it came to the financial challenges they faced, some participants noted how expensive it was for them to raise money for the therapy. Some people had to obtain bank loans to pay for their ART because their insurance did not cover the cost of their care. Some people had to reevaluate their goals in life, forgoing getting a car or a house in favor of starting a family. There have always been financial implications for ART treatment, however, the desire to have children seems to have always been a major driver despite this challenge [ 44 ]. This high cost oftentimes limits access and results in inequalities, where the more well-offs often have better access. Consequently, resolutions on infertility are limited to the wealthy [ 44 , 45 ]. Other individuals play critical roles in the use of ART apart from the women’s decision to use it. This study showed that the husbands of the women played important roles by giving them both material and emotional support throughout the procedure.They also received emotional, informational, and appraisal support from the mother, family members, and friends that strengthened them to continue their journey for a child until pregnancy and delivery were achieved. This observation is consistent with research by [ 46 ] who found that other individuals played important roles such as providing financial, and emotional support and referrals. The women in this study indicated that their mother-in-law’s expectations, social pressures in the form of hurtful words, nuances in people’s statements and behavior, baby announcements by spouses in church, and false prescriptions from sister-in-law prompted their use of ARTs. This is complemented by another study [ 47 ] which found that women were worried because some of the comments made by their peers, such as comparing them to their friends who got married in the same year, made them feel inferior. However in other studies, religion and the desire for satisfaction of a significant other in polygamy were enablers to the utilization of ARTs [ 48 ]. Women elsewhere were unperturbed and turned negative nuances into positive behavioral outcomes. The negative nuances rather, prompted the use of ARTs and in some cases increased usage [ 49 ]. More than half of the participants did not actively read or learn about infertility through other means but from healthcare professionals. This seems commonplace as others have reported the same mechanisms of information[ 50 – 52 ]. During the ART process, medical professionals offered their assistance as well. The study revealed that the doctors gave rapid attention to the women until a successful pregnancy and delivery were achieved. This result is comparable to one by [ 45 ], who discovered that women receiving ART were inspired by the helpful attitudes displayed by doctors and nurses. Furthermore, support was received from lay influencers who fueled their use of ARTs. While a study [ 42 ] reported that women were willing to discuss their challenges with others, an earlier study [ 53 ] reported opposing views, where women felt uncomfortable discussing with others as they feared being mocked. Some women also preferred discussing solely with spouses [ 54 ]. As seen in this study, the decision to the women to use ART and the enablers to use ART stem from varied factors such as IVF being an option, their desire to conceive, support from family members, their friends and their spouses. Also, the support from their mothers, getting useful information, the testimonies of other women that have succeeded in the use of IVF and the suggestions from the medical personnel also influenced their decision and equally enables them to use ART. These factors remain important in influencing the health and well-being of women with issues of infertility. The study objectives as reported in this study provides further insight on the major and minor contributory determinants of decision to use ART and enables to use ART among women. This study focused on an in-depth understanding of experiences among women with infertility who chose to access ART services. The findings provide us with a deeper understanding of how women eventually decide to use ART services as they live through infertility and what prompts have existed in their journey. However, this study is not without its limitations. The study did not include a vast group of females who are actively using ARTs and male partners who may have actively participated in the decisions in conception. Rather, this study collected data on infertility experiences among women within a support group. Thus, findings may not be generalized to the wider population or women in other support groups. Also, the interview guide was sent online via WhatsApp, therefore women who did not have access to the internet or WhatsApp-enabled devices or who may have had faulty devices were unable to participate in this research which limited opportunities for other women to contribute in sharing experiences. Face-to-face interactions provide the researcher with a direct observation of participant’s unspoken expressions which assist further in deciphering meanings. After several attempts at interacting face-to-face with participants failed, the researcher resorted to indirect communication which limited covert and overt observations which could have provided a richer environment of study for this qualitative approach of research.

Supplementary Material 1. Supplementary Material 1.