Women’s Lived Experiences of Decisional Conflict and Support Needs During First-Time Assisted Reproductive Technology Treatment: A Descriptive Phenomenological Study in China

Infertility, defined as the inability to conceive after 12 months of regular unprotected sexual intercourse, affects millions of couples worldwide. 1 Assisted reproductive technology (ART) has emerged as an effective intervention, resulting in more than 13 million live births. 2 In China, ART provision has expanded rapidly over the past two decades, driven by rising infertility prevalence, delayed childbearing, and evolving reproductive policies. 3 However, ART involves complex, multi-stage procedures including ovarian stimulation, oocyte retrieval, and embryo transfer, characterized by prolonged duration, substantial financial burden, and highly variable success rates dependent on maternal age, ovarian reserve or embryological factors. 4 Throughout the treatment course, patients face numerous high-stakes decision points that extend beyond purely clinical considerations. These include whether to initiate ART, whether to undergo oocyte retrieval under anesthesia, elective decisions regarding fresh versus frozen embryo transfer, whether to pursue preimplantation genetic testing (PGT) and how to interpret results, whether to transfer embryos diagnosed with mosaicism when PGT reveals such findings, and disposition decisions regarding surplus embryos following treatment completion or family building. 5 As a “hope technology” that promises biological parenthood while simultaneously extending uncertainty and emotional investment, ART occupies a distinctive space at the intersection of medical science, cultural values, and personal aspiration. 6 Despite professional guidance from healthcare providers, women remain central to ART decision-making, bearing a dual burden spanning biological, cognitive, and psychosocial dimensions. 7 Physically, they endure invasive procedures, including repeated injections, transvaginal ultrasound-guided oocyte retrieval, and embryo transfer, each carrying risks of complications and side effects. 8 Cognitively, they must rapidly process complex, often conflicting medical information under time-sensitive conditions, navigating high-stakes trade-offs between treatment risks and benefits, financial investment, and uncertain outcomes. 9 Psychosocially, they negotiate competing demands from spouses and extended family while reconciling internalized societal expectations of motherhood with personal values and bodily autonomy. 10 These cumulative burdens position women’s decisional conflict and perceived support as key influences on treatment engagement, psychological well-being, and reproductive outcomes. 11 Women undergoing initial ART encounter heightened decisional complexity. Without prior treatment experience, they struggle to anticipate the temporal, physical, and emotional demands of each phase, disrupting professional and personal routines. The frequent transvaginal ultrasound monitoring during ovarian stimulation necessitates rigid time management; 12 medication storage and injection schedules require strict adherence; 13 and recovery following oocyte retrieval demands temporary work adjustments. 14 Although women often seek out information about ART before commencing treatment, what they encounter comes from a patchwork of sources: healthcare professionals, relatives and friends, social media platforms including Bilibili and TikTok, and online patient communities, each differing markedly in reliability and accuracy. 15 , 16 This uneven information landscape frequently generates expectations that diverge from the actual physical, psychological, financial, and temporal realities of treatment, thereby amplifying decisional uncertainty among first-time patients and complicating their engagement with care. 17 , 18 Furthermore, first-time patients often maintain unrealistically optimistic expectations regarding treatment success, rendering the psychological impact of initial failure particularly severe. 19 Subsequent decisions, whether to continue treatment, modify protocols, or discontinue, are consequently shrouded in greater uncertainty. This decisional conflict is especially pronounced in family-centric cultural contexts where collective decision-making norms prevail. First-time patients must navigate treatment uncertainty while simultaneously negotiating care pathways with family members, creating a culturally specific dual burden that distinguishes their experience from that of patients in individualistic healthcare systems. The awakening of individual autonomy among Chinese women, driven by decades of universal education and increased digital connectivity, has fostered a growing demand for reproductive decision-making based on personal will and bodily autonomy. 20 Yet this shift coexists with persistent traditional familial ethics wherein fertility retains profound familial and social significance. 21 Consequently, women undergoing ART must navigate their decisions within a complex web of explicit and implicit pressures from spouses and extended family. These pressures encompass a spouse’s expectation for biological offspring, parental anxieties about lineage continuation, and intra-familial conflicts regarding treatment outcomes and risk burden. 22 Faced with such sustained familial expectations, women often internalize this pressure, framing ART as a pursuit for the family rather than a personal choice. This internalized, family-oriented motivation inherently conflicts with their underlying sense of individual sovereignty, creating a unique culturally situated dilemma for Chinese women in ART decision-making. Current research on ART has primarily focused on treatments, 23 patients’ psychological status, 24 and marital quality. 25 While such studies underscore growing recognition of infertile patients’ physical and mental health needs, they largely neglect the lived experience of the decision-making process itself. 26 Particularly within the context of Chinese traditional culture, where filial piety, familial expectations, and gendered norms profoundly shape reproductive choices, the decision-making trajectory and post-decisional experiences of first-time ART patients remain critically underexplored. To address this gap, our study integrates two complementary theoretical frameworks: Janis and Mann’s (1977) Decisional Conflict Theory (DCT), which conceptualizes decision conflict as arising from informational deficits, perceived inadequacy of social support, and outcome uncertainty; 27 and Social Support Theory, which delineates how emotional, informational, and instrumental support from spouses, family members, and healthcare providers differentially influences decisional processes and outcomes. 28 Together, these theories provide a robust foundation for systematically examining both the origins and manifestations of decision conflict in the first-time ART patient. To explore the lived experiences of decisional conflict and support needs of women during their first assisted reproductive technology (ART) treatment cycle, providing evidence for culturally appropriate decision support, psychosocial care, and patient-centered ART services.

This study employed a descriptive phenomenological approach, which centers on the principle of “returning to the things themselves” and emphasizes gaining an in-depth understanding of the lived experiences of women during decision-making for their first assisted reproductive treatment. The study is theoretically informed by Janis and Mann’s (1977) Decisional Conflict Theory (DCT) and Social Support Theory. 27 , 28 DCT posits that decision-making difficulties arise from insufficient information, inadequate support, and uncertainty about outcomes. Social Support Theory provides a framework for examining how emotional, informational, and instrumental support from spouses, family members, and healthcare providers influences the decision-making experience. These theoretical frameworks informed the development of interview questions and the interpretation of findings. Purposeful sampling was used to recruit women who met the inclusion criteria. “First-time ART” was defined as undergoing a first complete ART treatment cycle (from ovarian stimulation through embryo transfer). Recruitment and data collection continued until the research team judged that thematic saturation had been reached, defined as the point at which successive interviews generated no substantially new themes, dimensions, or meanings relevant to the research questions. Saturation was assessed through ongoing comparison of interview transcripts, codes, and developing themes by two members of the research team. Finally, we recruited 21 women who received assisted reproductive treatment for the first time at the Reproductive Medicine Center of our hospital from March to May 2026. A summary of their information is presented in Table 1 . Table 1 Demographic Characteristics of Patients (N= 21) No. Age Marriage Education Occupation Income Gravida-Parity History Cause of Infertility Types of ART Years Times P1 28 1.5 1 Bachelor Teacher 5001~10,000 G0P0 DOR IVF P2 33 1 1 Bachelor E-commerce >10,000 G0P0 Male Factor (Oligospermia) ICSI P3 36 12 2 Technical secondary school Individual household >10,000 G2P1 Bilateral Salpingectomy After Ectopic Pregnancy IVF P4 31 2 1 Bachelor Civil servant 5001~10,000 G0P0 Bilateral Tubal Obstruction IVF P5 24 3 1 Master Finance 5001~10,000 G0P0 Male Factor (OA) TESA P6 38 7 1 Senior high school E-commerce >10,000 G0P0 DOR IVF P7 41 12 1 Bachelor Saleswoman 5001~10,000 G2P1 Post-Right Salpingectomy IVF P8 35 2 1 Bachelor No 10000 G1P0 Single-gene disorder PGT-M P11 27 1 1 Junior college Saleswoman 5001~10,000 G0P0 Bilateral tubal obstruction IVF P12 39 5 2 Bachelor Electricity bureau staff 5001~10,000 G1P1 Male Factor (Asthenozoospermia) ICSI P13 29 3 1 Junior college Farmer 5001~10,000 G0P0 Abnormalities in the male’s chromosomes PGT-SR P14 28 1 2 Bachelor Logistics customer service 5001~10,000 G1P0 Post-Right Salpingectomy IVF P15 39 14 1 Bachelor Accountant 5001~10,000 G1P1 DOR IVF P16 36 3 1 Junior college E-commerce >10000 G0P0 Bilateral tubal obstruction IVF P17 43 1 1 Doctor Biological science researcher >10000 G0P0 Senior age; DOR NICS P18 36 4 1 Bachelor Clothing store manager >10000 G0P0 DOR IVF P19 40 6 1 Bachelor Bank clerk 5001~10,000 G0P0 DOR IVF P20 32 2 1 Master Lawyer >10000 G0P0 Bilateral Tubal Obstruction IVF P21 28 6 1 Junior college Farmer <5000 G1P1 Male Factor (Abnormal Sperm Morphology) PGT-A Notes : Age (years), DOR (Decreased ovarian reserve function), Education (Educational attainment), G0P0 (No history of pregnancy or childbirth), G1P0 (One pregnancy, no history of childbirth), G1P1 (One pregnancy, one childbirth history), Income (Per capita of the family: RMB. 10,000 RMB =rich. Abbreviations : IVF, In vitro fertilization; IVF-D, In vitro fertilization with donor sperm; ICSI, Intracytoplasmic sperm injection; NICS, Noninvasive chromosomal screening; N/No, Number; OA, Obstructive azoospermia; P(Participants; PGT-A, Preimplantation genetic testing for aneuploidy; PGT-M, Preimplantation genetic testing for monogenic conditions; PGT-SR, Preimplantation genetic testing for chromosomal structural rearrangements; TESA, Testicular sperm aspiration. Demographic Characteristics of Patients (N= 21) Notes : Age (years), DOR (Decreased ovarian reserve function), Education (Educational attainment), G0P0 (No history of pregnancy or childbirth), G1P0 (One pregnancy, no history of childbirth), G1P1 (One pregnancy, one childbirth history), Income (Per capita of the family: RMB. 10,000 RMB =rich. Abbreviations : IVF, In vitro fertilization; IVF-D, In vitro fertilization with donor sperm; ICSI, Intracytoplasmic sperm injection; NICS, Noninvasive chromosomal screening; N/No, Number; OA, Obstructive azoospermia; P(Participants; PGT-A, Preimplantation genetic testing for aneuploidy; PGT-M, Preimplantation genetic testing for monogenic conditions; PGT-SR, Preimplantation genetic testing for chromosomal structural rearrangements; TESA, Testicular sperm aspiration. Participants were selected based on the following criteria: a. married women aged over 20 years old (This is the legal marriage age for Chinese women. Only legally married infertile couples were permitted to undergo assisted reproductive treatment in hospitals); b. first-time assisted reproductive technology treatment; c. had completed at least one treatment decision (such as whether to initiate treatment or undergo embryo transfer); d. able to communicate normally; e. willingness to participate in the study and signing of the informed consent form. Exclusion criteria for this study comprised: a. Individuals with severe psychiatric disorders or cognitive impairments; b. Those unable to cooperate with the research. The study will be discontinued if: the participant voluntarily withdraws, or the researcher assesses that the participant’s physical condition is no longer suitable for continued participation. This study adheres to the Declaration of Helsinki. The ethical considerations of the study underwent a comprehensive review and received approval from the Ethics Committee of Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University (approval number: 2026–0461). Prior to the inclusion of each research subject, the responsible researcher provided them with a written, detailed account of the study’s purpose, nature, procedures, potential benefits, and risks. And the participants were informed that their anonymized responses would be published. They were given adequate time to consider participation before being included. Only after voluntary participation and signing of the informed consent form were research subjects included in the study. Participants’ personal information was anonymized, and only research team members had access to the audio recordings and transcripts. Participants could withdraw from the study at any time without any consequences. The research team comprised six members: two holding master’s degrees in nursing and four with bachelor’s degrees, all of whom had completed coursework in nursing research methodology and were proficient in research methods. All team members had received formal training in qualitative research. Following a comprehensive literature review and team discussions, a preliminary semi-structured interview guide was developed under the supervision of experts in qualitative research. Subsequently, two eligible patients were invited to participate in pilot interviews after providing informed consent; these pilot participants were not included in the final analysis, as their data were used solely to refine the interview guide. The final interview questions are as follows: a. How did you decide to undergo assisted reproductive treatment? What were your thoughts and concerns at that time? b. During the treatment decision-making process, what were you most worried about? What difficulties did you encounter? c. When making the treatment decision, who influenced you the most? How did they influence you? d. Did you ever hesitate or change your decision? What factors prompted you to make the final decision? e. During the treatment decision-making process, what help or support did you hope to receive? What support did you actually obtain? A private consultation room with a warm and quiet atmosphere was selected for conducting face-to-face semi-structured interviews with female patients who met the inclusion and exclusion criteria. The two trained interviewers conducted each interview together: one led the conversation using the semi-structured guide while the other took field notes and asked supplementary probing questions. Interview appointments were scheduled in advance with the patients. Prior to each interview, the researchers explained the research purpose, methods, confidentiality principles, and the necessity of audio recording. After obtaining informed consent, the interview was conducted according to the semi-structured interview guide. Throughout the interview, the researchers maintained linguistic neutrality, actively guided and encouraged participants, and promptly clarified their viewpoints. They listened attentively, encouraged participants to express their authentic feelings and experiences, avoided leading questions, and carefully observed and documented non-verbal behaviors, including facial expressions, speech rate, and tone of voice. Each interview lasted 30–45 minutes. Following each interview, the researchers summarized the k ey points and verified them with the participant to ensure accuracy (member checking). Following initial data analysis, a subset of participants was invited to review and confirm the identified themes, providing an additional layer of member checking. Within 24 hours, the audio recordings were transcribed verbatim and stored in NVivo software for analysis. Data collection and analysis were conducted concurrently. Following each interview, audio recordings were transcribed verbatim on the same day, with two researchers independently verifying the accuracy of the transcriptions. Data analysis was performed using Colaizzi’s seven-step phenomenological method, 29 which involved: (1) carefully reading all transcripts; (2) extracting significant statements; (3) coding recurring ideas; (4) grouping coded ideas into themes; (5) connecting themes with the research phenomenon and providing a comprehensive narrative; (6) identifying similar ideas and elevating them to overarching themes; and (7) returning the findings to participants for member checking. Two research team members independently engaged in repeated readings, organization, and categorization of the interview data to maximize the extraction of meaning. Coding was performed line-by-line, with initial codes compared and refined through iterative discussion. An audit trail was maintained throughout the analytic process, documenting decisions about coding, theme development, and interpretive choices. To ensure trustworthiness of the findings, multiple strategies were employed: credibility was established through prolonged engagement, member checking, and peer debriefing; dependability was ensured through the audit trail and the stepwise replication of analysis by two researchers; confirmability was supported by the inclusion of participant quotations and the grounding of interpretations in interview data; and reflexivity was addressed through bracketing and team reflection, as described above. Any discrepancies were resolved through discussion and consensus with the broader research team. Statistical power is not applicable to this qualitative study design; sample adequacy was instead justified through thematic saturation and information richness.

The study cohort comprises 21 individuals, aged 24 to 43 years. Tubal factors were the leading cause of infertility (33%), followed by decreased ovarian reserve (29%) and male factors (24%). Conventional IVF was the predominant treatment (57%), while ICSI and TESA were primarily used for male-factor cases. PGT-based approaches were applied for genetic indications. For further details, refer to Table 1 . The analysis yielded 3 themes and 9 sub-themes, which collectively illuminated the complex psychological landscape of first-time ART treatment decision-making among female patients. No substantial differences in thematic content were identified across demographic subgroups, including age, education level, and duration of infertility. The three overarching themes captured the dynamic interplay between internal psychological conflicts, relational dynamics, and adaptive processes: from the deeply personal struggles of navigating uncertainty and familial obligations (Theme 1: Inner Dilemmas in Treatment Decision-Making), through the social negotiation of support and resistance within the treatment decision-making arena (Theme 2: Support and Resistance in the Decision-Making Process), to the post-decision processes of reflection, hope, and life reconstruction (Theme 3: Adaptation and Reflection After Decision-Making). Notably, these themes were not mutually exclusive but rather operated as interconnected layers of meaning, with patients’ inner dilemmas persisting even as they received support, and their adaptive reflections emerging alongside continued anxieties. Regarding the main themes, sub-themes and topics, they are presented in Table 2 . Table 2 The Themes and Topics Themes Topics Theme 1: Inner Dilemmas in Treatment Decision-Making (1) Fear of Uncertainty Regarding Treatment Process and Outcomes “I have been afraid of injections since I was a child. When the doctor told me I needed daily ovulation-stimulating injections, I was really scared and thought for a long time before deciding to accept treatment. The doctor said the success rate is not 100%, which made me even more worried. I do not want all these injections to be for nothing” P3 “ I was trembling with nervousness on the day of oocyte retrieval. Although it was under general anesthesia, I still felt hollowed out after waking up. I do not know whether I should continue now, but I have already come this far. I am really afraid this time (embryo transfer) will not succeed, and I do not know how many more times I will have to go through this” P7 “ I am 39 years old this year. The doctor said my ovarian function is not good, and the number of oocytes is limited. At that time, I hesitated for a long time and searched a lot of information online before deciding to give it a try (accept treatment), but I really cannot bear the thought of failure” P15 “Every time I go to the hospital waiting for test results, my heart is in my throat. If the embryo quality is not good, or if implantation fails after transfer, perhaps I’ll have to give up on becoming a mother” P2 (2) Compromise Under Family Pressure and Expectations “ I originally wanted to rest for a while after freezing the embryos, but my mother-in-law has been urging us to have children. Every time we meet, she asks ‘when can I hold my grandchild?’ I feel like if I do not transfer the embryos immediately, I will be the sinner of the whole family” P5 “ Actually, I was hesitant inside and wanted to recuperate my body before starting. But my husband really wants children and can’t wait. I didn’t want to disappoint him, so I started with a stiff upper lip” P9 “My husband has always been good to me, but I always feel I owe him. He wants children, but I can’t give them to him. This sense of guilt has been weighing on me, and now I ask for my husband’s opinion on every treatment step” P6 “At that time, the doctor told me I could administer the ovulation-stimulating injections myself, which would make it convenient for me to calculate the dosage and avoid taking leave for injections, thus not affecting my work. I was really scared and felt I could not do it! But my husband said for the sake of our lovely child, I should be brave” P3 “My mother said to do it quickly while I am young, as it will be more difficult if I delay. She means well, but her anxiety is passed on to me, making me feel more pressured” P1 “Although my husband says he’s not in a hurry, I know he actually has expectations. When we go shopping, I can see how envious he is when he sees other people’s children. I feel that if I do not do this (assisted reproductive treatment), it will create a gap in our marriage” P12 (3) Anxiety About Self-Body and Role Value “I always wonder if I should ask the doctor to prescribe more medicine to regulate my body?” P9 “Watching my friends become mothers one by one, I feel particularly uncomfortable I feel that as a woman, I can’t even fulfill the most basic reproductive function. I feel I need more examinations, in case there’s some indicator affecting my pregnancy” P10 “Sometimes I wonder, if it ultimately fails, can our marriage still be maintained? Will he leave me because of this? The thought of these things fills me with pressure about the treatment. I hope the doctor can give me the best treatment plan and pay more attention to me” P8 Theme 2: Support and Resistance in the Decision-Making Process (1) Influence of Spousal Attitudes “We discuss problems together. My husband has always accompanied me. Every time I go to the hospital, he takes leave to go with me and helps me remember the doctor’s instructions. Having him there makes me feel the road ahead is not so difficult” P17 “He never gives me pressure, saying just do your best and don’t feel burdened. This understanding makes me feel like I’m not fighting alone” P19 “He never took the initiative to learn about these things; every time I come to the hospital alone. Sometimes I’m really angry, so I want to choose the most expensive medicine and find ways to spend his money!” P4 “Although my husband accompanies me to the hospital, he just finds a place to sit and play on his phone. I remember when the doctor discussed the ovulation stimulation plan with me, I really could not understand and did not know how to decide, but he (her husband) said to let me think for myself. At that time, I really felt helpless” P18 (2) Family Members’ Support and Intervention “My mother has always accompanied me, cooking for me and cleaning, allowing me to focus on treatment. She also comforts me and tells me not to be too nervous” P13 “After my mother-in-law learned we were doing IVF, she inquired about folk remedies everywhere and even asked me to take traditional Chinese medicine, saying natural conception is better than IVF. I know she means well, but her words make me more anxious, and I am eager to get pregnant to end all this” P1 “My parents are very supportive, saying as long as my body can handle it, they fully support me. They never give me pressure” “My parents-in-law do not know we are doing IVF. My husband will not let us tell them, afraid they will worry. This means I have to hide all the medicines at home. Once, medicines in a black bag were thrown away as garbage. After that, I asked the doctor to prescribe fewer medicines each time, and I would get more after using them up” P21 (3) Guiding Role of Healthcare Providers “The doctor patiently explained to me why my medication dosage was different from others’. This made me feel she was seriously considering my situation, and I was very willing to trust her” P20 “Once when a nurse saw I was nervous, she specifically came to hold my hand and comfort me, saying ‘you’ve worked hard.’ Just this one sentence made me feel truly understood. Later, when it came to transvaginal ultrasound or vaginal discharge collection, I would try to relax and cooperate with them” P11 “I feel the doctor is too busy; each consultation is very short, and many questions don’t have time to be asked, especially when I’m asked to make choices, my mind goes blank. I hope the doctor can give us more time and explain more” P16 “The nurse explained very clearly during health education, not only explaining to us face-to-face but also having us join a WeChat group where she sent self-made popular science videos that we could save and watch at home. This way, I could have a clear understanding of different medications and treatment plans, and know how to communicate effectively with the doctor when I return to the hospital” P9 Theme 3: Adaptation and Reflection After Decision-Making (1) Expectations and Anxiety About Treatment Outcomes “I spend a lot of time every day on Xiaohongshu checking posts about this, comparing my situation with others, as if this can predict whether I will succeed” P5 “General anesthesia seems terrifying to me; I have a sense of losing control. Anyway, I probably only have about 4 follicles, so I chose to have the oocyte retrieval surgery without anesthesia. But I am a bit afraid whether it will be very painful at that time” P8 “To increase the chances of pregnancy, I will choose to transfer 2 embryos. I hope I can succeed” P2 “I try not to think about the results, but I can’t control it. I feel this unknown outcome is more torturous than the injections” P12 (2) Self-Evaluation of the Decision-Making Process “Sometimes I wonder, was I too anxious? Should I have waited and recuperated my body more?”P3 “I don’t know if this decision is right, but since I’ve made it, I can only persist. Looking back now, I should have consulted more hospitals” P18 “I regret not starting earlier. The doctor said ovarian function declines year by year, and if I delay further, I might not even have a chance” P10 “I sometimes wonder if I should have chosen another option. The doctor said there were two choices, and I don’t know if I chose correctly” P4 (3) Re-Planning for Future Life “If this doesn’t succeed, I might consider adoption or accept a life without children. I think life has other meanings” P11 “I tell myself, no matter the outcome, I must live well and can’t pin all my happiness on having children” P9 “Even if it fails, I’ve tried my best with no regrets. Life must go on, and I’ll learn to accept” P17 “I plan to focus on work or develop new hobbies. I can’t let this thing define my life” P6 Abbreviation : P, Participant. The Themes and Topics Abbreviation : P, Participant. The first theme unveiled the psychological complexity of patients’ internal experience during initial ART decision-making. At its core lay a fundamental tension: between desire for treatment and fear of uncertainty, between autonomous selfhood and obligation to familial reproductive expectations, and between self-perception as capable women and emerging doubt about their bodies and reproductive worth. These dilemmas were not merely background emotional noise but central organizing principles shaping how patients engaged with. The three sub-themes reflected distinct yet interrelated dimensions of this inner turmoil. Patients’ narratives revealed that fear of the unknown operated as a pervasive psychological barrier requiring significant cognitive and emotional resources to overcome. The treatment process, characterized by invasive procedures, injectable medications, and uncertain timelines, confronted patients with threats to bodily integrity and personal control, while the statistical reality of success rates introduced an existential dimension of uncertainty many found difficult to bear. This anticipatory anxiety was particularly pronounced at the initial decision stage, where participants faced daily injections and the knowledge that success was not guaranteed. The medicalized nature of treatment, with its emphasis on probabilities and contingencies, heightened rather than mitigated these fears, as participants grappled with the possibility that their efforts might prove futile. P3 articulated this experience with striking clarity: I’ve been afraid of injections since I was a child. When the doctor told me I needed daily ovulation-stimulating injections, I was really scared and thought for a long time before deciding to accept treatment. The doctor said the success rate is not 100%, which made me even more worried. I don’t want all these injections to be for nothing. I’ve been afraid of injections since I was a child. When the doctor told me I needed daily ovulation-stimulating injections, I was really scared and thought for a long time before deciding to accept treatment. The doctor said the success rate is not 100%, which made me even more worried. I don’t want all these injections to be for nothing. The fear of uncertainty continued to pervade even the most physically invasive procedures, as evidenced by P7’s description of the oocyte retrieval experience: I was trembling with nervousness on the day of oocyte retrieval. Although it was under general anesthesia, I still felt hollowed out after waking up. I don’t know whether I should continue now, but I’ve already come this far. I’m really afraid this time (embryo transfer) won’t succeed, and I don’t know how many more times I’ll have to go through this. I was trembling with nervousness on the day of oocyte retrieval. Although it was under general anesthesia, I still felt hollowed out after waking up. I don’t know whether I should continue now, but I’ve already come this far. I’m really afraid this time (embryo transfer) won’t succeed, and I don’t know how many more times I’ll have to go through this. For participants with diminished ovarian function, the uncertainty carried particular poignancy, as reflected in P15’s account: I’m 39 years old this year. The doctor said my ovarian function is not good, and the number of oocytes is limited. At that time, I hesitated for a long time and searched a lot of information online before deciding to give it a try (accept treatment), but I really can’t bear the thought of failure. I’m 39 years old this year. The doctor said my ovarian function is not good, and the number of oocytes is limited. At that time, I hesitated for a long time and searched a lot of information online before deciding to give it a try (accept treatment), but I really can’t bear the thought of failure. The cumulative nature of uncertainty-related stress was evident in P2’s experience: “Every time I go to the hospital waiting for test results, my heart is in my throat. If the embryo quality is not good, or if implantation fails after transfer, perhaps I’ll have to give up on becoming a mother.” Beyond the intrinsic anxieties of medical uncertainty, participants commonly experienced psychological stress from perceived familial expectations and subsequent compromises in treatment decisions. This sub-theme reveals how the pursuit of motherhood within a family context transformed what might have been an individual medical choice into a relational negotiation laden with obligations, guilt, and fear of disappointing loved ones. Participants frequently surrendered personal preferences or bodily autonomy in response to pressure perceived as emanating from spouses, in-laws, and extended family networks. The gendered dimension of this pressure was particularly evident. Participants overwhelmingly reported feeling responsible for fulfilling reproductive expectations socially constructed as feminine obligations, creating a fundamental tension between their own physical and emotional needs and what they perceived as familial or spousal entitlements to grandchildren or biological continuation. P5 described the experience of being caught between her own wishes and her mother-in-law’s expectations: I originally wanted to rest for a while after freezing the embryos, but my mother-in-law has been urging us to have children. Every time we meet, she asks ‘when can I hold my grandchild?’ I feel like if I do not transfer the embryos immediately, I will be the sinner of the whole family. I originally wanted to rest for a while after freezing the embryos, but my mother-in-law has been urging us to have children. Every time we meet, she asks ‘when can I hold my grandchild?’ I feel like if I do not transfer the embryos immediately, I will be the sinner of the whole family. Similarly, P9 described deferring to her husband’s desires despite personal reservations: Actually, I was hesitant inside and wanted to recuperate my body before starting. But my husband really wants children and can’t wait. I didn’t want to disappoint him, so I started with a stiff upper lip . Actually, I was hesitant inside and wanted to recuperate my body before starting. But my husband really wants children and can’t wait. I didn’t want to disappoint him, so I started with a stiff upper lip The sense of indebtedness to a spouse who had been generally supportive was articulated by P6: My husband has always been good to me, but I always feel I owe him. He wants children, but I can’t give them to him. This sense of guilt has been weighing on me, and now I ask for my husband’s opinion on every treatment step. My husband has always been good to me, but I always feel I owe him. He wants children, but I can’t give them to him. This sense of guilt has been weighing on me, and now I ask for my husband’s opinion on every treatment step. P3 described a specific instance where spousal support became a form of gentle coercion: At that time, the doctor told me I could administer the ovulation-stimulating injections myself, which would make it convenient for me to calculate the dosage and avoid taking leave for injections, thus not affecting my work. I was really scared and felt I could not do it! But my husband said for the sake of our lovely child, I should be brave. At that time, the doctor told me I could administer the ovulation-stimulating injections myself, which would make it convenient for me to calculate the dosage and avoid taking leave for injections, thus not affecting my work. I was really scared and felt I could not do it! But my husband said for the sake of our lovely child, I should be brave. The transmission of maternal anxiety was described by P1: My mother said to do it quickly while I’m young, as it will be more difficult if I delay. She means well, but her anxiety is passed on to me, making me feel more pressured. My mother said to do it quickly while I’m young, as it will be more difficult if I delay. She means well, but her anxiety is passed on to me, making me feel more pressured. P12 reflected on the gap between her husband’s explicit statements and his implicit expectations: Although my husband says he’s not in a hurry, I know he actually has expectations. When we go shopping, I can see how envious he is when he sees other people’s children. I feel that if I do not do this (assisted reproductive treatment), it will create a gap in our marriage. Although my husband says he’s not in a hurry, I know he actually has expectations. When we go shopping, I can see how envious he is when he sees other people’s children. I feel that if I do not do this (assisted reproductive treatment), it will create a gap in our marriage. A particularly poignant dimension of participants’ psychological stress concerned their relationship with their own bodies and sense of personal value amid reproductive challenges. Many participants articulated a fundamental questioning of their feminine identity and worth, perceiving their bodies as defective or failing in relation to what they considered the most basic function of womanhood. This sub-theme reveals how infertility became not merely a medical problem but a source of profound identity disturbance, with feelings of inadequacy extending far beyond reproduction. Participants commonly engaged in self-blame and self-surveillance, interpreting their bodies as obstacles requiring constant monitoring and intervention. The treatment process itself became a site for ongoing self-evaluation, as participants questioned whether they were doing enough, whether their bodies were responding adequately, and whether their continued existence as non-mothers diminished their value as women and partners. P9’s brief but revealing statement captured this self-surveillance: I always wonder if I should ask the doctor to prescribe more medicine to regulate my body? I always wonder if I should ask the doctor to prescribe more medicine to regulate my body? The social dimension of bodily inadequacy was articulated by P10: Watching my friends become mothers one by one, I feel particularly uncomfortable I feel that as a woman, I can’t even fulfill the most basic reproductive function. I feel I need more examinations, in case there’s some indicator affecting my pregnancy. Watching my friends become mothers one by one, I feel particularly uncomfortable I feel that as a woman, I can’t even fulfill the most basic reproductive function. I feel I need more examinations, in case there’s some indicator affecting my pregnancy. Perhaps most disturbingly, participants expressed anxiety about their relational value and the stability of their marriages in the face of reproductive failure, as reflected in P8’s account: Sometimes I wonder, if it ultimately fails, can our marriage still be maintained? Will he leave me because of this? The thought of these things fills me with pressure about the treatment. I hope the doctor can give me the best treatment plan and pay more attention to me. Sometimes I wonder, if it ultimately fails, can our marriage still be maintained? Will he leave me because of this? The thought of these things fills me with pressure about the treatment. I hope the doctor can give me the best treatment plan and pay more attention to me. The second major theme captures how participants’ psychological experiences were profoundly shaped by the quality and nature of their support systems, which included spouses, extended family members, and healthcare providers. The findings reveal that support operated along a continuum. Positive support served as a protective factor enhancing coping capacity, while absent, unsupportive, or ambivalent support intensified psychological distress. Importantly, support was not a simple binary. Participants navigated complex relational landscapes in which the same individuals could provide both support and pressure, sometimes simultaneously. This theme illuminates the relational nature of psychological experience in reproductive difficulty, and how social dynamics could either empower or further disempower women grappling with bodily and identity challenges. Spouses occupied a pivotal position in participants’ support systems, serving as either primary sources of emotional sustenance or, conversely, as figures whose attitudes and behaviors contributed to psychological strain. The quality of spousal involvement varied dramatically, from active companionship and shared decision-making to mere physical presence without meaningful engagement. This sub-theme reveals that spousal support involved nuanced relational dynamics such as communication quality, emotional attunement, and distribution of treatment-related responsibilities, rather than being a simple matter of presence or absence. Participants with supportive spouses described feeling strengthened and accompanied, suggesting that shared experience of the treatment journey could transform an isolating ordeal into a relational project. Conversely, participants whose spouses were absent or minimally engaged bore additional burdens, navigating the medical system and managing treatment-related emotions without the anticipated support of their primary partners. P17 exemplified the positive impact of active spousal support: We discuss problems together. My husband has always accompanied me. Every time I go to the hospital, he takes leave to go with me and helps me remember the doctor’s instructions. Having him there makes me feel the road ahead is not so difficult. We discuss problems together. My husband has always accompanied me. Every time I go to the hospital, he takes leave to go with me and helps me remember the doctor’s instructions. Having him there makes me feel the road ahead is not so difficult. The protective function of non-pressuring spousal attitudes was described by P19: He never gives me pressure, saying just do your best and don’t feel burdened. This understanding makes me feel like I’m not fighting alone. He never gives me pressure, saying just do your best and don’t feel burdened. This understanding makes me feel like I’m not fighting alone. In stark contrast, P4 described the experience of spousal disengagement: He never took the initiative to learn about these things; every time I come to the hospital alone. Sometimes I’m really angry, so I want to choose the most expensive medicine and find ways to spend his money!. He never took the initiative to learn about these things; every time I come to the hospital alone. Sometimes I’m really angry, so I want to choose the most expensive medicine and find ways to spend his money!. The psychological toll of having a physically present but emotionally disengaged spouse was articulated by P18: Although my husband accompanies me to the hospital, he just finds a place to sit and play on his phone. I remember when the doctor discussed the ovulation stimulation plan with me, I really could not understand and did not know how to decide, but he (her husband) said to let me think for myself. At that time, I really felt helpless. Although my husband accompanies me to the hospital, he just finds a place to sit and play on his phone. I remember when the doctor discussed the ovulation stimulation plan with me, I really could not understand and did not know how to decide, but he (her husband) said to let me think for myself. At that time, I really felt helpless. Extended family members, including parents and in-laws, occupied variable positions in participants’ support systems, with involvement ranging from nurturing and sustaining to intrusive and anxiety-inducing. This sub-theme reveals that family support was highly context-dependent, shaped by relational histories, communication patterns, and the degree to which involvement was perceived as respectful of participants’ autonomy and emotional needs. Well-intentioned family involvement could paradoxically increase psychological distress when it failed to acknowledge participants’ emotional experience or imposed additional expectations. Participants consistently distinguished between family members who provided practical support without pressure and those whose involvement, however well-intentioned, contributed to their sense of burden. This distinction hinged on whether family members recognized participants as the primary stakeholders in treatment decisions or positioned themselves as having legitimate interests participants were obligated to fulfill. P13 described the experience of nurturing maternal support: My mother has always accompanied me, cooking for me and cleaning, allowing me to focus on treatment. She also comforts me and tells me not to be too nervous. My mother has always accompanied me, cooking for me and cleaning, allowing me to focus on treatment. She also comforts me and tells me not to be too nervous. In contrast, P1 described the experience of well-intentioned but anxiety-inducing intervention: After my mother-in-law learned we were doing IVF, she inquired about folk remedies everywhere and even asked me to take traditional Chinese medicine, saying natural conception is better than IVF. I know she means well, but her words make me more anxious, and I am eager to get pregnant to end all this. After my mother-in-law learned we were doing IVF, she inquired about folk remedies everywhere and even asked me to take traditional Chinese medicine, saying natural conception is better than IVF. I know she means well, but her words make me more anxious, and I am eager to get pregnant to end all this. The value of non-pressuring family support was articulated by P14: My parents are very supportive, saying as long as my body can handle it, they fully support me. They never give me pressure. My parents are very supportive, saying as long as my body can handle it, they fully support me. They never give me pressure. The need to conceal treatment from in-laws created additional psychological burdens, as described by P21: My parents-in-law do not know we are doing IVF. My husband will not let us tell them, afraid they will worry. This means I have to hide all the medicines at home. Once, medicines in a black bag were thrown away as garbage. After that, I asked the doctor to prescribe fewer medicines each time, and I would get more after using them up. My parents-in-law do not know we are doing IVF. My husband will not let us tell them, afraid they will worry. This means I have to hide all the medicines at home. Once, medicines in a black bag were thrown away as garbage. After that, I asked the doctor to prescribe fewer medicines each time, and I would get more after using them up. Healthcare providers, including physicians and nurses, served as significant figures in participants’ treatment experiences, functioning not merely as technical experts but as potential sources of emotional support and guidance. This sub-theme reveals that the quality of provider interaction could substantially influence participants’ psychological experience. Personalized attention and clear communication enhanced trust and reduced anxiety, while busyness and brief consultations contributed to feelings of abandonment and confusion. Providers occupied a unique position in participants’ support ecosystems, as the only professionals with both medical authority and direct knowledge of treatment trajectories. Participants consistently distinguished between healthcare experiences characterized by attentiveness and those marked by time pressure and impersonality. The desire for recognition of their individual circumstances and emotional needs was prominent, suggesting participants sought not only competent medical care but also relational acknowledgment of their humanity and suffering. The impact of personalized medical explanation was described by P20: The doctor patiently explained to me why my medication dosage was different from others’. This made me feel she was seriously considering my situation, and I was very willing to trust her. The doctor patiently explained to me why my medication dosage was different from others’. This made me feel she was seriously considering my situation, and I was very willing to trust her. The profound impact of emotional attunement by nursing staff was articulated by P11: Once when a nurse saw I was nervous, she specifically came to hold my hand and comfort me, saying ‘you’ve worked hard.’ Just this one sentence made me feel truly understood. Later, when it came to transvaginal ultrasound or vaginal discharge collection, I would try to relax and cooperate with them. Once when a nurse saw I was nervous, she specifically came to hold my hand and comfort me, saying ‘you’ve worked hard.’ Just this one sentence made me feel truly understood. Later, when it came to transvaginal ultrasound or vaginal discharge collection, I would try to relax and cooperate with them. In contrast, the experience of healthcare provider time pressure and its consequences was described by P16: I feel the doctor is too busy; each consultation is very short, and many questions don’t have time to be asked, especially when I’m asked to make choices, my mind goes blank. I hope the doctor can give us more time and explain more. I feel the doctor is too busy; each consultation is very short, and many questions don’t have time to be asked, especially when I’m asked to make choices, my mind goes blank. I hope the doctor can give us more time and explain more. The positive impact of comprehensive health education was exemplified by P9: The nurse explained very clearly during health education, not only explaining to us face-to-face but also having us join a WeChat group where she sent self-made popular science videos that we could save and watch at home. This way, I could have a clear understanding of different medications and treatment plans, and know how to communicate effectively with the doctor when I return to the hospital. The nurse explained very clearly during health education, not only explaining to us face-to-face but also having us join a WeChat group where she sent self-made popular science videos that we could save and watch at home. This way, I could have a clear understanding of different medications and treatment plans, and know how to communicate effectively with the doctor when I return to the hospital. The third major theme captures participants’ psychological experiences regarding treatment decision-making and the reconstruction of future orientations amid reproductive uncertainty. This theme reveals how participants engaged in ongoing processes of evaluation and re-evaluation, questioning past decisions while simultaneously constructing contingencies for possible futures that might not include biological motherhood. The findings illuminate the temporal dimension of psychological experience in ART, as participants oscillated between hope and acceptance, regret and resolution, navigating the fundamental uncertainty of their reproductive futures while maintaining psychological continuity and coherence. Participants consistently exhibited a paradoxical relationship with treatment outcomes, simultaneously hoping for success and dreading failure, with uncertainty generating persistent anticipatory anxiety. This sub-theme reveals how the uncertain future of reproductive treatment became a focus of psychological preoccupation, with participants engaging in various behaviors to manage or reduce uncertainty. These included social comparison, information seeking, and formulating expectations about treatment processes and results. Outcome uncertainty was not merely intellectually recognized but emotionally embodied, becoming a persistent source of distress coloring participants’ daily experience. The use of social media for comparison and prediction was described by P5: I spend a lot of time every day on Xiaohongshu checking posts about this, comparing my situation with others, as if this can predict whether I will succeed. I spend a lot of time every day on Xiaohongshu checking posts about this, comparing my situation with others, as if this can predict whether I will succeed. The anxiety surrounding medical procedures themselves was articulated by P8: General anesthesia seems terrifying to me; I have a sense of losing control. Anyway, I probably only have about 4 follicles, so I chose to have the oocyte retrieval surgery without anesthesia. But I am a bit afraid whether it will be very painful at that time. General anesthesia seems terrifying to me; I have a sense of losing control. Anyway, I probably only have about 4 follicles, so I chose to have the oocyte retrieval surgery without anesthesia. But I am a bit afraid whether it will be very painful at that time. The formulation of treatment expectations was described by P2: To increase the chances of pregnancy, I will choose to transfer 2 embryos. I hope I can succeed. To increase the chances of pregnancy, I will choose to transfer 2 embryos. I hope I can succeed. Perhaps most powerfully, P12 articulated the torturous quality of outcome uncertainty: I try not to think about the results, but I can’t control it. I feel this unknown outcome is more torturous than the injections. I try not to think about the results, but I can’t control it. I feel this unknown outcome is more torturous than the injections. Participants commonly engaged in retrospective evaluation of their treatment decisions, questioning whether choices had been correct, whether alternative paths might have been preferable, and whether they had been sufficiently informed or deliberative. This sub-theme reveals how decision-making amid reproductive uncertainty was rarely experienced as resolved, but remained subject to ongoing psychological review. Retrospective doubt was particularly acute when outcomes were unknown or negative, and could become an additional source of distress compounding treatment challenges. The phenomenon of second-guessing was evident across participants with varying treatment histories, suggesting retrospective doubt may be an inherent feature of decision-making under uncertainty rather than a response to specific failures. P3 articulated this experience with notable clarity: Sometimes I wonder, was I too anxious? Should I have waited and recuperated my body more? Sometimes I wonder, was I too anxious? Should I have waited and recuperated my body more? The relationship between commitment and doubt was described by P18: I don’t know if this decision is right, but since I’ve made it, I can only persist. Looking back now, I should have consulted more hospitals. I don’t know if this decision is right, but since I’ve made it, I can only persist. Looking back now, I should have consulted more hospitals. The painful recognition of timing-related regret was articulated by P10: I regret not starting earlier. The doctor said ovarian function declines year by year, and if I delay further, I might not even have a chance. I regret not starting earlier. The doctor said ovarian function declines year by year, and if I delay further, I might not even have a chance. P4 expressed more generalized decision doubt: I sometimes wonder if I should have chosen another option. The doctor said there were two choices, and I don’t know if I chose correctly. I sometimes wonder if I should have chosen another option. The doctor said there were two choices, and I don’t know if I chose correctly. Faced with uncertain treatment outcomes, participants engaged in the psychological work of imagining and preparing for alternative futures that might not include biological motherhood. This sub-theme reveals how participants constructed contingency orientations, developing frameworks for acceptance and meaning-making that allowed them to maintain psychological continuity and wellbeing regardless of outcomes. The capacity to imagine alternative futures was not equivalent to giving up hope, but represented a sophisticated psychological strategy for managing the threat of potential failure. Participants who articulated such contingency frameworks did not necessarily expect or desire treatment failure, but demonstrated psychological preparedness that allowed them to face uncertainty without existential terror. This capacity for “hopeful contingency thinking” appeared to provide a foundation for emotional resilience. The articulation of alternative pathways was described by P11: If this doesn’t succeed, I might consider adoption or accept a life without children. I think life has other meanings. If this doesn’t succeed, I might consider adoption or accept a life without children. I think life has other meanings. The framing of outcome-independent wellbeing was articulated by P9: I tell myself, no matter the outcome, I must live well and can’t pin all my happiness on having children. I tell myself, no matter the outcome, I must live well and can’t pin all my happiness on having children. P17 expressed the relationship between acceptance and peace: Even if it fails, I’ve tried my best with no regrets. Life must go on, and I’ll learn to accept. Even if it fails, I’ve tried my best with no regrets. Life must go on, and I’ll learn to accept. The determination to maintain identity beyond treatment was described by P6: I plan to focus on work or develop new hobbies. I can’t let this thing define my life. I plan to focus on work or develop new hobbies. I can’t let this thing define my life.

Participants’ accounts suggest that decisional conflict involved more than information deficits and was closely connected to procedural, outcome-related and existential uncertainty. Family involvement operates as a double-edged sword, simultaneously supporting and pressuring patients within the Chinese relational selfhood framework. Healthcare providers serve as emotional anchors rather than mere information sources, yet current clinical structures often undermine this role. Decisional conflict extended beyond the initial treatment choice into ongoing processes of reflection, self-evaluation, and meaning-making. These findings challenge the view of ART decision-making as a discrete cognitive event and underscore the need for a processual, relationally attuned, and culturally appropriate model of care. The proposed psychosocial care directions, including pre-treatment orientation, structured counseling, psychosocial screening, and digital support, represent preliminary suggestions based on the findings and require further evaluation through longitudinal, multi-center, couple-based, and intervention research.

The findings of this descriptive phenomenological study illuminate the complex, multifaceted nature of decisional conflict experienced by first-time women undergoing ART. Through in-depth interviews with 21 participants, three overarching themes emerged: inner dilemmas in treatment decision-making; support and resistance in the decision-making Process; adaptation and reflection after decision-making. These themes reveal that women’s experiences with ART decisions extend far beyond the simple weighing of treatment options, encompassing existential uncertainties, relational dynamics, and ongoing processes of meaning reconstruction. The first key finding is that uncertainty operates as a core dimension of decisional conflict for first-time ART patients, extending well beyond the information deficits emphasized in traditional decision-making models. While participants did express a need for comprehensive medical information—consistent with DCT’s emphasis on information adequacy— our data reveal that uncertainty in first-time ART is experienced as multi layered: procedural uncertainty (ambiguity about treatment steps and timelines), outcome uncertainty (unpredictability of success rates and complications), and identity uncertainty (existential questions about womanhood and motherhood when reproductive capacity is compromised). 30 This identity uncertainty can be usefully framed through Bury’s (1982) 31 concept of biographical disruption—the idea that serious illness or impairment can interrupt taken-for-granted assumptions about one’s life trajectory, identity, and sense of normality. While infertility is not equivalent to chronic illness, participants’ narratives revealed analogous forms of disruption: they described feeling “behind” their peers in the expected life course, questioning their identity as women and potential mothers, and revising previously held plans for family formation. As one participant expressed, “reading about it is completely different from actually going through it,” highlighting the inherent limitations of information-based approaches to uncertainty reduction. This observation resonates with Zhou (2025), 32 who identified uncertainty as a significant predictor of emotional fluctuations among ART patients, and with Copp et al (2020), 33 who documented that couples struggle to balance hope with realistic expectations. Importantly, a recent large-scale mixed-methods study 34 found that 41% of fertility patients met criteria for PTSD or complex PTSD, with uncertainty and loss of control identified as central themes in patient narratives—suggesting that the uncertainty experienced at the initial decision point may not merely be a cognitive challenge but a potential precursor to clinically significant distress when left unaddressed. These findings call for multi-level uncertainty interventions. First, at the procedural level, reproductive clinicians are advised to implement a structured pre-treatment orientation program—comprising a short video walkthrough of the treatment timeline, a written “what to expect” booklet containing answers to common questions at each stage, and a 15-minute nurse-led question-and-answer session—to reduce ambiguity about treatment steps and timelines. Second, at the outcome level, clinicians should replace population-level success rate statistics with individualized prognostic counseling that presents realistic probability ranges tailored to the patient’s age, diagnosis, and ovarian reserve, supplemented by a brief decision aid that facilitates values clarification about acceptable risk thresholds. 35 Third, and most critically, at the identity level, clinics should integrate a one-time pre-decision counseling session (30–45 minutes) conducted by a trained fertility counselor that explicitly invites patients to discuss fears about womanhood, bodily integrity, and future life scenarios; such sessions should normalize existential uncertainty as a common, legitimate experience rather than a deficit to be eliminated. Participants reached a consensus that family members (including spouses and collateral relatives) function as both sources of support and stressors. A study 36 utilizing data from 257 Chinese couples undergoing assisted reproductive technology (ART) conducted a latent class analysis, identifying four distinct couple coping patterns. Among these, 33.1% of couples were categorized as adopting “common negative coping styles”, indicating that the duality of support and stress is not merely an individual-level phenomenon but a relational and patterned dynamic at the couple level. Our findings further reveal the cultural specificity of autonomy within the Chinese context: while Western bioethics prioritizes individual autonomy, participants described a relational decision-making approach deeply embedded in family ties and cultural narratives surrounding the maternal role. This observation aligns with the concept of relational autonomy in prenatal testing decisions proposed by Lau et al (2016) 37 and is further substantiated by Lo (2022), 38 who expounded on the notion of “dialectical family imagination” in Chinese women’s reproductive decision-making processes—emphasizing that decisions are concurrently shaped by filial emotions, personal goals, and the need to negotiate socio-political norms of heteronormativity. In contrast to Lau et al’s focus on prenatal testing, our study demonstrates that relational autonomy operates even in the pre-treatment decision-making phase, where the stakes of negotiating family expectations may be particularly pronounced. Notably, women affected by male-factor infertility may encounter a distinct dynamic: while the etiological factor lies with their partners, the associated pressure and expectations are disproportionately borne by the women. This gendered asymmetry is also evidenced in another study, which found that social support for infertile men in China moderates the relationship between fertility stress and quality of life—suggesting that gendered expectations shape both the provision and reception of support in the context of infertility. 39 These findings point to three specific strategies for managing family involvement. First, reproductive clinicians should identify couples in the “common negative coping” profile who may benefit from targeted couple-based intervention. 40 For couples identified as high-risk, a structured 4–6 session couple counseling protocol—adapted from systemic transactional model-based interventions and focused on improving stress communication, supportive coping, and joint meaning-making—should be offered. 41 Second, given the cultural salience of extended family pressure, an optional “family communication facilitation” session should be offered in which a counselor helps the patient (and, if willing, her partner) develop concrete communication scripts for setting boundaries with in-laws. Third, for cases involving male factor infertility, clinicians should proactively initiate a brief psychoeducational conversation with both partners about the common pattern of “unspoken causation,” in which the medical fact of male factor etiology remains socially invisible while the woman bears the relational burden; normalizing this dynamic may reduce guilt, blame, and the relational avoidance described by several participants. Participants described providers in contrasting modalities: as sources of attentive, individualized attention and empathetic engagement, and as hurried professionals constrained by time pressures. This distinction is clinically significant: while information provision remains fundamental to informed consent, our data show that information alone is insufficient to resolve decisional conflict. The manner in which information is conveyed, the provider’s attentiveness, and the emotional tenor of the encounter emerged as decisive factors. One participant (P11) described how a provider’s simple acknowledgment—“you have worked hard”—felt more supportive than extensive medical explanations. Conversely, P16 reported that time pressure rendered information provision ineffective; despite extensive verbal information, she felt overwhelmed and unable to process it meaningfully, echoing literature on cognitive load in clinical settings. An innovative finding concerned digital platforms extending provider support: P9 described a WeChat-based educational group offering ongoing information and peer support between visits, aligning with emerging evidence on e-health interventions for ART patients. 42 These findings call for concrete changes to clinical practice structure and provider training. First, clinics should implement a “two-track consultation” for first-time patients: a 20-minute medical consultation focusing on procedural information and prognosis, followed by a separate 15-minute psychosocial check-in (by a trained nurse or counselor) addressing emotional readiness, unresolved concerns, and family dynamics—ensuring information delivery and emotional processing occur in distinct, adequately timed encounters rather than one rushed appointment. Second, clinics should adopt a distress-informed care protocol including: (a) routine emotional screening at first visit using validated brief measures (eg, the 4-item Patient Health Questionnaire for anxiety/depression); (b) a structured “acknowledge–validate–support” communication framework, training providers to begin consultations with brief recognition of the patient’s emotional effort (eg, “I know this isn’t easy”) before medical content; and (c) a clear referral pathway to fertility-specific psychological services for patients with significant distress. Third, digital support platforms (eg, WeChat-based educational groups as described by P9) should be formally integrated into the care pathway as supplementary resources between visits, with professional moderation and scheduled information at key milestones to reduce cognitive overload during in-person consultations. Participants described ongoing self-evaluation, meaning reconstruction, and life re-planning that persisted long after the initial treatment decision, extending our understanding of decisional conflict as not merely a discrete event but an ongoing psychological process reverberating throughout the treatment journey. Traditional DCT has focused primarily on the pre-decisional phase, offering limited conceptual resources for understanding longer-term reflection, meaning-making, and adaptation. Our findings address this gap. Participants engaged in retrospective evaluation—assessing whether they had been adequately informed and whether their choices had been authentically their own—which was deeply affective, involving regret, satisfaction, or conditional acceptance. This aligns with broader literature on meaning reconstruction following adverse experiences, suggesting that the ART decision-making experience, while profoundly stressful, may also serve as a catalyst for adaptive change: deepened resilience, clarified life priorities, and enhanced appreciation for relational connections. 43 Participants also described evolving coping strategies—cognitive reframing, emotional expressiveness, seeking support, and a “one step at a time” approach—that developed over time, suggesting that the initially overwhelming experience may foster competencies serving patients throughout their treatment journey. These findings indicate that post-decision psychosocial follow-up should be systematized rather than left to ad hoc clinician discretion. We propose three specific components. First, a structured “decision reflection” session (20–30 minutes) scheduled 2–4 weeks after the initial treatment decision, using a semi-structured guide prompting patients to revisit their decision experience: “How do you feel about your decision now?” “Is there anything you wish you had known?” “Does anything about the decision still trouble you?” This session creates sanctioned space for ambivalence, regret, or unresolved uncertainty to surface before they compound into chronic distress. Second, clinics should implement routine psychosocial monitoring at three key transition points—after the initial decision, after the first treatment cycle (regardless of outcome), and at treatment discontinuation—using brief validated instruments (eg, the Decisional Conflict Scale combined with a distress symptom screener such as the PCL-5) to identify patients whose post-decision trajectory is shifting toward distress rather than adaptive change, enabling timely referral to specialized psychological care. Third, for patients who have completed treatment without achieving a live birth, a structured meaning reconstruction intervention—such as a 4-session narrative therapy program adapted from Gameiro and Finnigan’s (2017) work on adjustment to unmet parenthood goals—should be offered, providing a guided framework for integrating the treatment experience into a coherent life narrative and renegotiating identity beyond the motherhood role. 44

Several limitations must be acknowledged. First, the study was conducted at a single clinical site in Eastern China, potentially limiting transferability to other cultural contexts or healthcare systems. Second, the cross-sectional design precludes examination of how the decision-making experience unfolds over time; a longitudinal design tracking patients from initial consultation through treatment and beyond would provide richer understanding of temporal dynamics. Third, participants’ accounts are subject to social desirability bias inherent in self-report methods. Fourth, the study focused exclusively on women’s experiences; incorporating partners’ perspectives would provide a more complete picture of dyadic decision-making. Despite these limitations, the findings offer valuable insights for clinical practice. Future research should extend this work through multi-center studies, longitudinal designs examining trajectories of decisional conflict, dyadic studies incorporating couples’ perspectives, and intervention research evaluating targeted support strategies for first-time ART patients.