This research study was carried out at the Centre of Assisted Reproduction and Embryology (CARE), Queen Mary Hospital, Hong Kong. Based on medical records, individuals who are Chinese and who have undergone DAC at CARE and delivered offspring successfully between 2008 and 2013 were invited to participate in this study. It is crucial to ensure participant confidentiality, as the acceptance of DAC and the level of social stigmatization remains unknown in Chinese community. Disclosure of identifying information may result in damaging psychosocial impact on the resulting child, the recipient women and the families. Taking into account the policy on patient confidentiality in Institutional Research Board and Hospital Authority of Hong Kong, study invitations were only carried out by the gynaecologist who was the clinician-in-charge in CARE with authorized access to patient records. Invitation letters and participant information sheets were sent out three times to potential informants through emails between August 2013 and August 2014. Contact details were given to the researchers only when the potential informants responded to the invitation and indicated their consent to be contacted by the researchers. As patient information was considered highly sensitive, the number of women who declined the invitation and their demographic characteristics were not disclosed to the researchers.

Based on components extracted from the theory of planned behavior (Ajzen, 2011) and elements from theories related to gender identity (West & Zimmerman, 2009), an interview guideline was developed assessing three domains: self (attitudes, perceived control, self-identity, guilt, loss of genetic link), family (parenthood, importance of childbearing, relationship with in-laws) and social (subjective norm and perceived stigmatization of being infertile and undergo infertility treatment). Each in-depth interview lasted for approximately 2 hours.

The interview audio recordings were transcribed verbatim into Cantonese, then translated into English for analysis. Interpretative Phenomenological Analysis (IPA), a widely-used qualitative method in health psychology research (Burbeck & Willig, 2014; Williams, McManus, Muse, & Williams, 2011) was employed. The present study aims to create an in-depth analysis of women who experienced conceiving a child through DAC. As required by the IPA methodology, a small sample is sufficient for this purpose (Smith, 2011). The core of IPA places heavy emphasis on the relationship among informants’ meaning-making, thoughts, beliefs and cognition (Flowers, Duncan, & Knussen, 2003). IPA essentially involves a dual interpretation process, in which the researcher makes sense of the participants’ making sense of their experience (Smith & Osborn, 2008). First, the researcher went through the set of translated transcripts and attached short interpretative notes (or codes) to passages where participants recollected and explained their subjective experience. The researcher then categorizes these codes into themes, which have emerged from the individual interviews. When repetitions of themes are found across individual transcripts, it is an indication that these themes indeed reflect shared experience and perceptions among the participants. The recurrent themes were first extracted by the first author. After her supervisor critically reviewed the recurrent themes, minor amendments of the interpretations were made. The set of recurrent emerging themes were then developed into a theoretical framework with regard to the psycho-socio-cultural context relevant to the study participants. The final set of themes and the theoretical framework were approved by both the first author and her supervisor. NVivo 10 was used to facilitate the process of coding and aggregating themes.

Between February and December 2014, eight Chinese mothers who had experienced DAC and had successfully given birth to a resulting child or children agreed to participate in in-depth semi-structured interviews, either in person or by video-conferencing. Of these eight participants, three are recipients of SD, four are recipients of OD and one is recipient of ED. The basic information of these informants is listed in Table 1. The average age of informants at the point of interview was 42.5 years old and the average age of the resultant offspring was 2.8 years old. Two out of eight informants had another child from natural conception either before or after the birth of the DAC-conceived child. All participants were married at the point when the interviews took place. Due to the relatively small sample pool, additional information that may identify the informants has been purposely omitted in order to guarantee confidentiality. The recurrent themes are extracted and presented in Figure 1. Explanation of each component are described in detail with informants’ quotes taken from interviews.

Figure 1. 
Adoption of DAC is seen as a protection among infertile couples

A strong desire to have children was observed in some informants. Remaining childless was not an option in their concepts of family formation. One informant displayed a strong sense of guilt towards herself and her marriage:

(after knowing husband’s infertility) I tried to adjust myself. I reckon if we cannot have a child of our own, I will just adopt a child. No matter what we have to have a child. (SD recipient)

I want to have kids. I love children, that’s why I choose this job (to be surrounded by children). (SD recipient)

I am deeply sorry. We really need to have a child. (OD recipient)

Regardless of being diagnosed with a female or male infertility factor, these Chinese women expressed that infertility had adversely affected their marital relationships. Several informants articulated that due to their inability to have children and the stress that it induces, separation and divorce may be foreseeable in the future:

more or less, men do mind (the infertility of their wives) […] I told him, if you do mind and want to find another woman, just tell me. In fact there was once he considered leaving me, almost […] his friends asked him to find another wife […] if you use my infertility as an excuse, I cannot refute […] after all it is not uncommon, my friend’s husband filed for divorce because of her childlessness. (ED recipient)

(after an argument) I asked him to leave. At that moment, I suddenly realize since you cannot give me what I need and we cannot have a complete family […] I said to him since we are not compatible, maybe separation is an option. He said let’s divorce. He was never that angry before and he really left. We didn’t (divorce) but only resume contact after almost a year. (SD recipient)

If not (having a child of our own), my husband and I may need to separate eventually. (OD recipient)

The traditional cultural association between women and fertility is deeply rooted. The experience of infertility is internalized by individuals and affects their identity and sense of self (Olshansky, 1987). Some women displayed a distorted sense of self solely based on their reproductive ability:

I told my husband about my infertility way before our marriage. The reason for telling him is to give him a choice. If he cannot accept it, we break up. After all I am a defect. I worried he would blame me after getting married. (ED recipient)

The IVF results came back negative, (due to the advanced age) I described myself as “high input, no outcome” […] all these hurting me so much. (OD recipient)

To summarize, this section illustrated the impact of infertility on women’s conceptualization of womanhood and their marital relationship. For these women, being infertile resulted in a distorted sense of self as a whole. The thought of being childless was unacceptable to the informants. The absence of a child means an incomplete family and intense guilt for the mother. A negative impact on marital relationships was also observed. It was evident that some women were wrestling with several predicaments resulting from childlessness, including marital instability, intense guilt, and a distorted sense of womanhood.

When women start to identify themselves as infertile, they also start to engage in the full range of reparative measures, i.e., taking on all sorts of infertility treatments in hopes of pregnancy (Olshansky, 1987). Informants included in this study displayed reluctance in accepting childlessness and showed unwavering determination to find a solution to their infertility. Often, women proactively sought help from assisted reproductive technologies. Before employing DAC and accepting the loss of genetic connection with the child, some women experienced a lengthy and harrowing process of exhausting all other kinds of ARTs with the use of their own gametes.

(after 5 rounds of IVF) We changed another doctor to try one more round, it failed again. At the point, I talked to my husband maybe we need to accept the fact that we need egg donation. (OD recipient)

After a year of trying to get pregnant, we went to see a private doctor. He suggested we can try IUI first. After 2 rounds of unsuccessful IUI, we undertook one round of IVF […] then we changed another doctor because her clinic was closer to my workplace. Then she found out I had two chocolate cysts, but we did not do the removal surgery as the doctor worries the surgery may affect my chance of pregnancy. I tried 3 more rounds of IVF with her that lasted more than a year, but we were still unable to get pregnant […] Then we stopped and wondered if it was possible to increase our chance of success if we find another doctor […] We tried another 2 rounds of IVF with the third doctor but again it failed. (OD recipient)

Informants also reported experiencing physical pain while undergoing ART procedures. However, perhaps the more scarring effects of undergoing the lengthy ART process were the resultant psychological and emotional upheavals that couples experience. Some women reported deteriorating physical health while others described it as a physically painful process:

I failed the first round of IVF with the first private doctor I visited […] the second one was also a private doctor but she asked me to be bed-bounded for 2 weeks […] I did exactly what the doctor asked but turns out it failed, what was worse was that I felt so unwell for the next couple of months, the world seemed like it was spinning all the time […] I went to see another O&G doctor who recommended me to go for ICI, only then they realize the problem with my husband’s sperm, and the embryo did not implant this round either […] it was the fifth doctor we visited suggested we should consider egg donation […] from the first doctor until the point we chose egg donation, it was around 7-8 years. (OD recipient)

The whole process (of IVF) is hard. The needles were huge. So painful. It was a very hard period. (OD recipient)

Some informants had failed numerous IVF cycles before accepting the use of donated gametes to conceive. Informants were asked to retrospectively recall their initial emotions after the failed IVF cycles and miscarriage after IVF failures. Many expressed their disappointment and frustration, yet they displayed a sufficient level of resilience to manage the negative emotions afterwards:

I went to visit many Westerner doctors as well we Traditional Chinese practitioners. Some doctors said I don’t have any oocytes, some said the size (of the follicles) too small. I was depressed but I motivated myself to keep my hope. (OD recipient)

We succeeded (to get pregnant) the first time, we were so excited yet nervous. But it lasted for two months only, its heart stopped. I was so shocked and upset […] I could feel it inside me. He/she would be 10 years old if we didn’t lose it […] the more you hope for, the stronger the disappointment. Up till now, I still feel very sorry about it. (ED recipient)

I failed three times of IVF cycles before. In between, I conceived naturally once. Quite excited, I was finally pregnant. But it’s gone after 7 weeks. We checked with another gynecologist, he also said the fetus’ heart stopped […] of course I was so disappointed. But I kept telling myself not to put too much hope on it. Yes I was frustrated but I still managed to continue the following IVF cycles. (OD recipient)

Except for one informant who previously had bilateral oophorectomy, this section describes how informants and their partners with fertility difficulties chose to engage in various treatments, including Traditional Chinese treatments and ARTs. Prior to their acceptance of the use of donated gametes, the exhaustion of these treatments had a strong impact on the women’s physical and mental wellbeing.

Loss of genetic connection is an inevitable result for those who chose DAC to conceive. The psychosocial impact of DAC is often compared with adoption. Recipients of DAC may have considered the possibility of adoption, but in the end opted for DAC due to the perceived externalities associated with adoption:

I have given him (husband) the choice between sperm bank and adoption […] adoption may create even more problems because adoption forced him to face the face his infertility directly. Alternatively, if we used sperm bank, we can have our own children in which the relationship and the feeling is natural. And we do not need to face the life-long problems like adoption does. (SD recipient)

My husband and I did consider going for adoption but only if we fail the sperm donation. It is because there are so many things to explain if we chose adoption and we are uncertain if our families can accept this. I still have frozen embryos, we decide to use up all these first before going for adoption. (SD recipient)

These accounts reflect how informants view adoption as a confirmation for their infertility, and therefore opted for DAC instead. The use of DAC allows for a degree of secrecy whereas adoption does not.

The process of being pregnant for ten months, as a rite of passage to motherhood, is absent in adoption. By going through the childbearing process, the parent-child relationship is perceived to be established regardless of the loss of genetic connection:

Even though I do not have the genetic connection with the child (when using embryo donation), I did experience the pregnancy process, there must be some blood connection between us. By giving birth to him, it is to confirm our mother-child relationship, he (her son) cannot say I am not his mother. The main difference laid in the fact that I do not carry the baby for 10 months if we choose to adopt. Unless we are so lucky to adopt a good child, I will otherwise worry a lot and it cause distress to the parent-child relationship. (ED recipient)

I reckon the actual 10-month of childbearing is so much more important than the genetic connection. Nothing is more important than this process of building the bonding with him […] The bonding is strong, when I was carrying him, seeing him from the ultrasound, and when he is born, feeling him. (OD recipient)

Having a child is seen as an important element of family formation. In cases where the husands were diagnosed with infertility, women expressed a wide range of emotions, including anger, frustration and distress:

I was angry, very angry. I was thinking what’s wrong with him, he should go for body check before getting married. I want a family, and he cannot give it to me. (SD recipient)

I was so upset. My disappointment even grew to despair I should say. (SD recipient)

On the other hand, disappointments were exhibited in the husbands who suffered infertility. Unlike women, the coping strategies used by these husbands for their frustrations were to isolate themselves from anything that relates to reproduction. Given the avoidance coping strategies used by men, women who received SD indicated that it was they who initiated the idea of using donated gametes:

He stayed in a very depressed stage for more than a month (after knowing his infertility). He instructed me not to mind his business, he will figure things out. But I know him well, he was not trying to find solution, just trying to run away from the problem. (SD recipient)

In the whole process of choosing donor, he was not involve at all. I reckon he was just trying to avoid any scenarios that he needed to discuss anything he did not want to. So he left it all to me to decide […] when I showed him the donor I chose, he just ‘um’ to indicate okay. That is it. (SD recipient)

Women recipients acknowledged the negative impact of male infertility on men. Many recipients suggested infertility in men was often related to the damage of their dignity or manhood.

I think men’s ego are even stronger, feeling loss of face. It is hard to admit it is “not working”. I am a woman, I felt bad when I was asked about my fertility. But if it is the man who face infertility, I can imagine he will be so much more painful than I do. (ED recipient)

Men with infertility suffered a lot more than women, because it is their responsibility to carry on the family line. Women do not have such a huge responsibility thus female infertility is less serious. (SD recipient)

From the point of view of female recipients, the use of donated sperm is a good way to prevent husbands from losing face and the information related to his infertility can be concealed.

Using anonymous sperm donor was our best choice. Otherwise, if anyone knows about it, it is a huge damage to my husband’s dignity. It is like announce to the world that he has fertility problem. (SD recipient)

Maybe men are more bounded by Traditional Chinese value. They perceive infertility as a failure of a whole person. Men themselves think others look down on them for their fertility difficulties […] now he has a son and no longer think of his infertility anymore. (SD recipient)

In those cases with the wives who were diagnosed with infertility, informants’ husbands favored the use of donated oocytes. Informants often used the word his own child to emphasize the genetic connection between the father and the child. Informants showed their determination in preserving the right of their partners’ to have their own children with the intention to alleviate their guilt in their inability to perform their roles as wives.

The reason of accepting egg donation is that the child is genetically connected to my husband. My husband is so much happier to have his own child. (OD recipient)

I have never considered (to go for adoption) as my husband would like to have his own child. The technology is so advanced now, it is such blessing to many families like us, why should we give up so early? (OD recipient)

I am good with either having children or being childless, but my husband really wants a child. Then I suggested adoption, he firmly said no. He said he cannot accept to raise someone else’s child. He said the child has to be genetically connected to him. (OD recipient)

Frequently, infertility per se did not cause the direct pressure on Chinese women. Rather, it was the social pressure from the families or extended families that did. In many cases, the pressure to have children was exerted by parents-in-law. For relatively conservative Chinese families that view childbearing as something women must fulfil as wives, it was not uncommon to ascribe blame to the wife. Conceiving with DAC seemed to be the way to uphold the marriage.

The use of oocyte donation is the best option we have […] my parent-in-law put so much pressure on me, in fact ever since they realized my infertility from my husband’s dairy, they hindered our courtship. And my relationship with them went from bad to worse after we got married. We failed several cycles of IVF. That’s why we reckon we cannot procrastinate anymore. (OD recipient)

After failing the IVF for so many times, the motivation to continue was totally because of him (the husband). He really wants to have a child of his own, I should comply with his wishes […] with all the injections, the process was so painful. I was in the mentality that be ready to risk everything for it. He really wants it, so just let’s keep doing it. (OD recipient)

In traditional Chinese culture, infertility brings shame and guilt not only to the women but also to the parents-in-law. Conceiving through DAC provides a protective shield for the parent-in-law as well:

The pressure (from parent-in-law) subsided with my pregnancy […] They felt the birth of the child alleviated the shame among relatives and friends, and more importantly they dare to face the ancestors of the family. (OD recipient)

The physical conditions of my parent-in-law were getting worse. But their situations are gradually improving when they have these two grandsons. That’s why the old saying is right: family is the best medicine. (SD recipient)

This section describes how the employment of DAC provides a chance to alleviate guilt that is associated with infertility and serves as a protection for their marriage. The traditional patrilineal family model of Chinese culture has clearly defined childbearing as one of the most important duties of daughters-in-law (Shih & Pyke, 2015). The social pressure of having children was evident within the Chinese community. Inability to fulfill the filial duties frequently resulted in intensive guilt. Interestingly, guilt was not simply triggered by women themselves, but also from husbands sand parents-in-law.

Informants and their partners described the employment of donated gametes as the last resort after failing all other kinds of ART. This is due to the fact that the use of donated gametes threatens another traditional Chinese value: the concept of qin shen. Qin Shen refers to the blood connection between the parent and children and is highly valued. Even when motherhood could be materialized, genetic discontinuity is still an issue of concern for women who gave birth through DAC. One participant believed that the difference in childrearing between parents may be rooted in the genetic discontinuity with one parent:

At a point during my pregnancy, I have this thought that since the baby is only related to my husband but not me, will there be a chance, when the son found out the truth, that he will decide to love me not as much […] it is just a thought when I was carrying the baby. I have this thought that I have to protect myself too. (OD recipient)

Both are not related to him. When the children were born, I was worried. I was not sure of the reasons, but he seemed to be quite distanced from the children. He didn’t help much with the childrearing during their infancies. (SD recipient)

The distancing created by the genetic disconnection has been acknowledged by women who have experienced DAC. Some informants indicated their initiative to find ways to lessen such distancing:

The nature (between naturally-conceived and DAC-conceived motherhood) has no difference. If there is any, it is me being more deliberate in building the relationship between the father and sons. I was worried, in the beginning, that their father may treat them differently. (SD recipient)

In fact, my relationships with my two (DAC-conceived) children were even better than my eldest (natural-conceived) child. I took on the life as a full-time mother and spend so much quality time with the young ones. (OD recipient)

These testimonials illustrate how informants and their partners recognize the possible distancing originated from the loss of genetic connection. The behavioral outcome of such acknowledgement in women who utilized DAC was shown in their parenting choice. In a way, the purposeful action in building strong bonds between the DAC-conceived child and oneself or the infertile partner was carried out with the hope to compensate for the lack of genetic connection.

All of the informants were asked, “if you could turn back time, do you have any regret and would you do anything differently in terms of conceiving through DAC?” Not one of the informants have regretted their choice of using donated gametes.

I regret I did not do it earlier. I am so contented to have my daughter. I am so happy. (SD recipient)

No regret, only happiness. I am still thankful to see the information about donated gametes in the clinics. In fact I tried to pregnant with the remaining embryos in the past two years. (OD recipient)

I knew you will ask me this question. I can firmly tell you that nothing is more important than my son right now. He is more important than anything. I can lose everything but not my son […] I won’t regret having him even I endured so much pain to bring him to the world. (SD recipient)