When Failed Motherhood Threatens Womanhood: Using Donor-Assisted Conception (DAC) as the Last Resort

Introduction

Since the dawn of humanity, childbearing has dominated the lives of many women. Women with fertility difficulties frequently experience a measurable level of grief and depression (Lukse & Vacc, 1999). Infertility is widely defined as the inability to conceive after a year of regular unprotected intercourse. The number of years with infertility was associated with severity of depression (Ramezanzadeh et al., 2004). Interestingly, gender differences in encountering infertility were observed: it was found that women experienced comparatively higher levels of infertility-related stress than men, regardless of the infertility being caused by male or female factor (Nachtigall, Becker, & Wozny, 1992). Such gender differences may be a reflection of how infertility affects gender identity. Womanhood is a socio-cultural and psychological construct central to female identity, closely tied to physiological events and bodily experiences. In the case of infertility, the inability to conceive and to give birth to achieve motherhood seemingly forced women to cast doubts on their own womanhood (Ticinelli, 2012).

The connection between womanhood and motherhood may be explained by the concept of doing gender, a psychologically ingrained social construct that conditions and shapes behavior according to one’s gender (Butler, 2006). It follows that behaviors are often assessed based on socially accepted conceptions and expectations of gender (West & Zimmerman, 2009). When women are unable to do gender by giving birth, this could threaten their sense of identity as normal women (Loftus & Andriot, 2012). In terms of conforming to gender roles, social expectations vary across cultures. In Chinese culture, producing a male heir to continue the patriarchal family line has been one of the most important filial responsibilities historically enforced upon women (Chan, Blyth, & Chan, 2006). A century ago, the inability to produce an offspring would constitute a legitimate reason for husbands to divorce or abandon their wives (Van Gulik, 1995). The status of women in a family, or even in the extended family, was determined by the quality and quantity of the male heir(s) she gave birth to. A Chinese proverb, mu ping zi gui, i.e., “a mother relied on her son to be precious”, indicates that the value of a woman was determined by her sons (Wang & Tang, 2004). Now, the acceptance of childlessness in Chinese communities is at its highest in history, as reflected by the declining fertility rates from 2.35 in 1990 to 1.62 (births per women) in 2016 in China (World Bank Group, 2018). Notwithstanding these contemporary trends, social expectations of childbearing are still strongly imposed on women (Han, 2006). In the most recent available study examining the attitudes toward filial practices among Chinese undergraduates, despite their ambivalence or positive attitudes towards childlessness, participants still expressed that they have to have a child to fulfill their parents’ expectations (Deutsch, 2006).

Donor-assisted conception (DAC) has been used internationally for more than three decades since the inception of advanced technology in assisted reproduction, in-vitro fertilization (IVF), in 1978 (Lopata, Brown, Leeton, Talbot, & Wood, 1979). The implementation of sperm donation (SD) in the form of artificial insemination can be dated back to the 17th century (Hard & Minn, 1909). It was frequently used by couples when the male partner either did not respond to assisted reproductive treatments or refused to undergo other medical interventions (Horowitz, Galst, & Elster, 2010a). Oocyte donation (OD) is often utilized by women with medical conditions, like premature ovarian failure, as well as for those with other issues, like delaying childbearing age (Marcus & Brinsden, 1999). Likewise, embryo donation (ED) has been chosen by couples when both partners encounter difficulties in conception.

Infertility and childlessness are often seen as failure in accomplishing filial piety in Chinese philosophy. Consequently, the inability to fulfill the child-bearing duty may result in intense guilt (Chan et al., 2002) and identity crisis (Tsui, 2014). While Western studies suggest that individuals do not necessarily feel morally obliged to possess the ability that they do not hereditarily hold, Chinese individuals tend to experience higher levels of guilt over a responsibility they cannot accomplish even though the ability to fulfil such task is absent (Bedford & Hwang, 2003). For these individuals, the adoption of DAC could be an opportunity for them to achieve parenthood. More importantly, DAC may allow female recipients to fulfil their gendered role and to restore their social identity as women.

Previous researches on the application of DAC have focused on issues of disclosure—the controversy between the mother’s right to conceal information regarding infertility and use of DAC, versus the child’s right to know (e.g., Horowitz, Galst, & Elster, 2010b), or on the motivation to donate gametes (e.g., Massey et al., 2011). Existing studies on the social implications of DAC have been conducted in the West while little is known about the Asian experience. To shed light on the disclosure controversy, a Canadian study (Hershberger, Klock, & Barnes, 2007) analyzed the experience of women who conceived through OD. It was found that women’s decisions to reveal or disclose their DAC experience were influenced by their social and cultural environment, such as social support and family culture, which shaped their values and beliefs regarding the right to know and the duty to protect. As connotations of childbirth and fertility vary greatly between different cultures, DAC-related research findings may not be generalizable. It is important to develop culturally contextualized studies on DAC before controversial issues such as disclosure can be discussed in non-Western countries.

In Hong Kong, approximately 70 cycles of DAC with IVF are performed annually (Council on Human Reproductive Technology, 2015). Only legally married heterosexual couples are allowed to employ assisted reproductive technologies. Although the use of DAC is gaining in popularity in Hong Kong, clinical guidelines or legislation on DAC disclosure have not been created. Adequate research and public consultation on the social implications of DAC are necessary to inform the creation of guidelines and legislation. At present, none of the existing studies have explored the impact of DAC on womanhood and identity, or how DAC relates to the traditional values of fertility and genetic continuity in Chinese communities. It is important to understand how Chinese women perceive infertility, what motivates them to choose DAC, and its impact on their psychosocial wellbeing. An in-depth understanding on the experience and perceptions of DAC recipients shall add to the knowledge base regarding its social implications.

The current study was conducted to examine the impact of infertility and the use of DAC on womanhood in the Chinese community. This study aims to examine the lived experiences of women who succeeded in giving birth through DAC by addressing the following research questions: In the case of female-factor infertility (i.e., OD), how do women make sense of their infertility in relation to their womanhood and motherhood? In the case of male-factor infertility (i.e., SD), how do women perceive their role in producing an offspring to continue the family bloodline? For those with male and/or female infertility (i.e., ED), how does the loss of genetic continuity between both parents and the child affect the way women perceive their womanhood?

Method

Results

Demographic Characteristics

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

Discussion

While infertility has a negative impact on womanhood, multiple domains where the employment of DAC could function as a protective shield for women’s social identity have been identified. For infertile Chinese women who had experienced DAC, the protective shield of DAC comprises of four elements: protection of self-identity, protection of marriage, protection of the husband’s dignity and protection of information by concealing infertility. Despite the loss of genetic connection with the child, the process of childbearing allows women to turn the previously unfavorable circumstances into a form of protection of womanhood. Furthermore, they are mindful of their parenting practice and deliberately nurtured the emotional bonds between themselves and their husband and children. In retrospect, none of the women regrets the decision to use DAC.

Despite the fact that women now have more freedom to expand their social roles and life choices, findings from this study suggest that the social construct of fertility could still be a vital element of being a woman in Chinese culture. Women who experienced DAC in this study found an utmost importance in childbearing, and the guilt and shame of infertility have made them feel necessary to conceal the infertility through DAC. Such tendencies for women to shoulder the responsibility of childbearing for the patriarchal family and to develop psychosocial stress from perceived stigma are also common in other male-dominated Asian societies such as Japan (Matsubayashi et al., 2004). Likewise, in Western societies, women still feel incomplete when they failed to fulfil motherhood (Greil, 2002) and blame themselves for the infertility (Péloquin, Brassard, Arpin, Sabourin, & Wright, 2017).

Guilt and shame, sense of isolation, and compromised marital relationship were also reported in another Hong Kong study (Loke, Yu, & Hayter, 2012). Our findings on infertility-related psychosocial distress in women have also found parallel cases in Western countries. For example, in Scotland, more than 25% of infertile women reported concerns in self-esteem and self-blame (Anderson, Sharpe, Rattray, & Irvine, 2003). Likewise in Denmark, women reported significantly higher infertility-related stress in the personal and social domain than men (Schmidt, 2006). Pro-natal values may be internalized in women, regardless of the level of modernization.

The experience of pressure from in-laws, however, may be unique to Asian countries. For example, in Taiwan, parents-in-law were reported to influence the marital satisfaction of infertile couples (Sun & Lee, 2000). In Japan, it was found that 52.7% of infertile women felt pressured primarily by their mother-in-law (Matsubayashi et al., 2004). Our findings suggest that while womanhood is threatened by failing the social expectations to do gender (Loftus & Andriot, 2012), this can be remedied by using DAC where women could experience pregnancy and perform the gendered work of labour.

This study demonstrates how women have used DAC as a means to restore their social identity, protect the family from societal pressure, and fulfill patriarchal family expectations. Due to the predominant focus of ART on women’s bodies, it is often women who undergo physical, mental, and relational risks with infertility before finally resorting to DAC (Reis, Xavier, Coelho, & Montenegro, 2013). When DAC was successful, women felt rewarded by a new-found meaning upon acceptance and acknowledgement by their significant others, despite the fact that the child has no genetic linkage to the male or female side. They also felt able to protect the dignity of their husband and maintain the harmony of the patrilineal family by continuing its legacy.

The Chinese society is a collectivist culture that values the ancient Confucian teachings of filial piety and natural obligation to family members. Confucian philosophy advocates that a virtuous woman should put family harmony as their ultimate goal, which could be achieved by respecting the elders, practicing filial piety, and practicing three kinds of obedience: obedience to the father before marriage (zai jia cong fu), obedience to the husband once married (chu jia cong fu), and obedience to the son when the husband has passed away (fu si cong zi) (Ding, 2002). One may argue that Confucianism has declined in the modern society with the rising socio-economic status of women. Yet, the philosophy is still reflected in our familial system and social policy (Leung, 2014). The perception of women who have undergone DAC is in accord with these traditional beliefs as they put the wishes of their husbands and the expectations of their in-laws over and above their own wishes (Fan, 1997). In doing so, their well-being is often compromised.

The suffering of infertile women may be attributed to the devaluation of oneself as a subservient member of the family, with a lack of awareness or resistance against patriarchal social expectations imposed upon them (Galhardo, Pinto-Gouveia, Cunha, & Matos, 2011). In clinical practice, health counsellors for women who contemplate or have underwent DAC should exercise cultural sensitivity and attend to issues faced by specific ethnic groups, for example the aforementioned pressure from parents-in-law on women from Asian ethnicities. Findings in this study may inform clinical practice and contribute to the drafting of guidelines in health counseling, especially amongst ethnic minorities who encounter more pronounced gender inequality, as well as inequality in accessing information and resources concerning infertility treatments (Goodwin, 2005). In Hong Kong, although infertile couples could obtain comprehensive information regarding the benefits and risks of treatment options, it is not commonplace for clinicians to discuss the relevant psychosocial issues that should be taken into consideration before making a decision.

It has been reported that physicians are more likely to provide information on treatment success and the direct risks of physical treatment, while often neglecting to mention the possibility of multiple unsuccessful pregnancies and its emotional consequences (Rauprich, Berns, & Vollmann, 2011). While couples contemplating DAC should be informed about the risks of medical complications, they should also be facilitated to reflect on their beliefs and motivation to undergo DAC, and assisted to balance the benefits of DAC against possible consequences on women’s physical and psychological health. Amongst the successful cases reported in this study, DAC has presented numerous benefits for women’s subjective well-being. It allows them to fulfil their dream of motherhood, achieve a sense of womanhood, and restore their marital harmony. Nevertheless, health professionals should empower women to contemplate the effects of culture and patriarchy on female identity, so that they can make informed choices regarding whether or not to undergo infertility treatments, and if it is necessarily to give birth (De Berardis et al., 2014).

Assisted reproductive technologies have been increasingly popular with the medicalization of infertility since the 1980s (Whiteford & Gonzalez, 1995), which has helped to perpetuate the pro-natalist belief that families should have children. Women who are voluntarily or involuntarily childless are considered deviant and stigmatized (Forsythe, 2009). It has been reported that 13% of women experienced suicidal ideation following a failed IVF treatment (Bringhenti, Martinelli, Ardenti, & Battista La Sala, 1997). In clinical practice, health counselors may assist these couples to explore alternatives other than pursuing further treatment (Boivin & Kentenich, 2002). Couples may benefit from support to overcome social pressure and consider non-biological family options such as adoption and fostering (Greil, Slauson-Blevins, & McQuillan, 2010). Health counselors may also assist infertile couples to normalize childlessness, by helping them construct a child-free identity, with freedom to pursue career aspirations and flexibility in time and money (Tanturri & Mencarini, 2008). Men and women have been reported to experience distress as a result of repeated failure in ART, particularly amongst those with a tendency to use self-blame and distancing coping strategies (Peterson, Newton, Rosen, & Schulman, 2006). Cognitive behavioral (Newton, 2006) and narrative approaches (Diamond, 1999) have shown to be effective in repairing relationship crises in infertile couples, eventually helping them adjust to the life of a childless family. With adequate help and support, couples have been found to experience enhanced marital relationship through weathering the emotional storm and making sense of the life experience of being infertile (Peterson, Pirritano, Block, & Schmidt, 2011; Schmidt, Holstein, Christensen, & Boivin, 2005).

Limitations

This is a phenomenological analysis that recruited only a small number of women who underwent successful DAC treatment. As an in-depth study of women’s personal experience, it may be subjected to self-selection bias. Although the sample size is adequate for using IPA to explore the lived experience of individuals (Smith, 2011), it should not be seen as representative of women’s general experience of DAC. Moreover, the male perspective was not included in this study although it is a domain worthy of further study. For example, it has been reported that male factor infertility affects sexual and personal quality of life and unknown-factor infertility brings about social stress in men (Smith et. al., 2009). It should be noted that the female-only perspective of couple dynamics described herein is not free of subjective bias.

Suggestions for Further Studies

One of the most controversial issues with DAC is the dilemma between the right of privacy among recipient parents and the right of the offspring to have full access to their genetic origins (Horowitz et al., 2010b). Future research may elaborate the protective functions of DAC with regard to infertility information concealment issues. In families that have used either oocyte or SD, only one of the parents is genetically connected with the resulting child. Disclosure of the child’s genetic origin and social history largely depend upon the parent’s decisions. Our current findings may serve as the foundation for further studies on the pattern of information concealment among Chinese women who experienced DAC. The present study offers a detailed account of the psychosocial impact of infertility on women under multiple sources of pressure, and their use of DAC to protect valued relational domains. These include a harmonious relationship with oneself as a woman and mother, the marital relationship, and the relationship with in-laws. Our study findings reveal how women used DAC to conceal the infertility in order to protect the husband’s dignity and to maintain family relationships. Future studies may explore the reasons and ways in which women would conceal or disclose their DAC experience, and contribute towards substantiating women’s perspective within the DAC disclosure controversy.

Conclusion

Traditional Chinese culture values the continuity of the patrilineal line. Even in modern times, infertility is often seen as a woman’s inability to fulfill family obligations, creating social stigmatization for the woman as defective. Ironically, advances in science have provided an ideal solution to perpetuate the age-old tradition of patriarchy. Women would go to great lengths to preserve the socially acceptable version of womanhood as a mother, as it has been internalized as a central domain of their female identity. Assisted reproductive technology with the use of donated gametes provides an option for infertile couples to fulfill their dream of parenthood, and for infertile women to restore their womanhood. By understanding the distinctive psychosocial profile of women who have undergone DAC, this study has paved the way for further research on counseling women regarding the experience of DAC and the information concealment controversy.

Acknowledgments

* This research received a Small Project Grant in The University of Hong Kong and this paper is funded by Faculty Development Scheme, Research Grants Council, Hong Kong.

** The current research is part of the author’s doctoral study.

Gratitude to Prof. Cecilia Chan, Prof. Ernest Ng and Dr. Celia Chan, The University of Hong Kong, for their guidance.

References

• Anderson, K. M., Sharpe, M., Rattray, A., & Irvine, D. S., (2003), Distress and concerns in couples referred to a specialist infertility clinic, Journal of Psychosomatic Research, 54, p353-355. [https://doi.org/10.1016/s0022-3999(02)00398-7]
• Ajzen, I., (2011), Theory of planned behavior, In P. A. M. Lange, A. W. Kruglanski, & E. T. Higgins (Eds.), The handbook of theories of social psychology, p438-459, London, SAGE.
• Bedford, O. A., & Hwang, K. K., (2003), Guilt and shame in Chinese culture: A cross‐cultural framework from the perspective of morality and identity, Journal for the Theory of Social Behavior, 33, p127-144. [https://doi.org/10.1111/1468-5914.00210]
• Boivin, J., & Kentenich, H., (2002), Guidelines for counselling in infertility, ESHRE Special interest group on psychology and counselling. Retrieved from http://orca.cf.ac.uk/34955.
• Bringhenti, F., Martinelli, F., Ardenti, R., & Battista La Sala, G., (1997), Psychological adjustment of infertile women entering IVF treatment: Differentiating aspects and influencing factors, Acta Obstetricia et Gynecologica Scandinavica, 76, p431-437. [https://doi.org/10.3109/00016349709047824]
• Burbeck, R., & Willig, C., (2014), The personal experience of dysmenorrhoea: An interpretative phenomenological analysis, Journal of Health Psychology, 19, p1334-1344. [https://doi.org/10.1177/1359105313490313]
• Butler, J., (2006), Gender trouble: Feminism and the subversion of identity, New York, Routledge.
• Chan, C. L. W., Blyth, E., & Chan, C. H. Y., (2006), Attitudes to and practices regarding sex selection in China, Prenatal Diagnosis, 26, p610-613.
• Chan, C. W., Yip, P. F., Ng, E. Y., Ho, P. C., Chan, C. Y., & Au, J. K., (2002), Gender selection in China: Its meanings and implications, Journal of Assisted Reproduction and Genetics, 19, p426-430.
• Council on Human Reproductive Technology, (2015), Treatment services provided by centers with treatment licenses, Retrieved from http://www.chrt.org.hk/english/licensed/files/treatment_eng.pdf.
• De Berardis, D., Mazza, M., Marini, S., Del Nibletto, L., Serroni, N., Pino, M. C., & Di Giannantonio, M., (2014), Psychopathology, emotional aspects and psychological counselling in infertility: A review, Clinical Therapy, 165, p163-169.
• Deutsch, F. M., (2006), Filial piety, patrilineality, and China’s one-child policy, Journal of Family Issues, 27, p366-389. [https://doi.org/10.1177/0192513x05283097]
• Diamond, R., (1999), Therapeutic approach in the late lmmersion phase: The donor decision, In R. Diamond, D. Kezur, M. Meyers, C. Scharf, & M. Windshel (Eds.), Couple therapy for infertility, p150-159, New York, The Guilford Press.
• Ding, D., (2002), Marriage customs of remote past reflected in the kinsfolk appellation of mourning apparel in ceremonial etiquette, Journal of Henan University, 3, p54-57, (In Chinese).
• Fan, H., (1997), Footbinding, feminism and freedom: The liberation of women’s bodies in modern China, London, Frank Cass.
• Flowers, P., Duncan, B., & Knussen, C., (2003), Re‐appraising HIV testing: An exploration of the psychosocial costs and benefits associated with learning one’s HIV status in a purposive sample of Scottish gay men, British Journal of Health Psychology, 8, p179-194. [https://doi.org/10.1348/135910703321649150]
• Forsythe, S., (2009), Social stigma and the medicalization of infertility, Journal of the Manitoba Anthropology Students’ Association, 28, p22-36.
• Galhardo, A., Pinto-Gouveia, J., Cunha, M., & Matos, M., (2011), The impact of shame and self-judgment on psychopathology in infertile patients, Human Reproduction, 26, p2408-2414. [https://doi.org/10.1093/humrep/der209]
• Goodwin, M., (2005), Assisted reproductive technology and the double blind: The illusory choice on motherhood, Journal of Gender, Race & Justice, 9, p1-54.
• Greil, A. L., (2002), Infertile bodies: Medicalization, metaphor, and agency, In M. C. Inhorn, & F. Van Balen (Eds.), Infertility around the globe: New thinking on childlessness, gender, and reproductive technologies: A view from the social sciences, p101-118, Berkeley, University of California Press.
• Greil, A. L., Slauson‐Blevins, K., & McQuillan, J., (2010), The experience of infertility: A review of recent literature, Sociology of Health & Illness, 32, p140-162. [https://doi.org/10.1111/j.1467-9566.2009.01213.x]
• Han, J. W., (2006), Re-examination of changes and remains of male-oriented family and filial piety considering low fertility rate, Asian Women, 22, p97-116.
• Hard, A. D., & Minn, M., (1909), Letter to the editor: Artificial impregnation, The Medical World, 27, p163-164.
• Hershberger, P., Klock, S. C., & Barnes, R. B., (2007), Disclosure decisions among pregnant women who received donor oocytes: A phenomenological study, Fertility and Sterility, 87, p288-296. [https://doi.org/10.1016/j.fertnstert.2006.06.036]
• Horowitz, J. E., Galst, J. P., & Elster, N., (2010a), Sperm donation and recipiency, In J. E. Horowitz, J. P. Galst, & N. Elster (Eds.), Ethical dilemmas in fertility counseling, p107-127, Washington, DC, American Psychological Association. [https://doi.org/10.1037/12086-000]
• Horowitz, J. E., Galst, J. P., & Elster, N., (2010b), Offspring born of collaborative reproductive arrangements: Issues of disclosure and third-party identification, In J. E. Horowitz, J. P. Galst, & N. Elster (Eds.), Ethical dilemmas in fertility counseling, p141-168, Washington, DC, American Psychological Association. [https://doi.org/10.1037/12086-000]
• Leung, L. C., (2014), Confucian welfare: A barrier to the gender mainstreaming of domestic violence policy in Hong Kong, In S. Sung, & G. Pascall (Eds.), Gender and welfare states in East Asia: Confucianism or gender equality?, p114-136, Basingstoke, Palgrave Macmillan.
• Loke, A. Y., Yu, P. L., & Hayter, M., (2012), Experiences of sub‐fertility among Chinese couples in Hong Kong: A qualitative study, Journal of Clinical Nursing, 21, p504-512. [https://doi.org/10.1111/j.1365-2702.2010.03632.x]
• Loftus, J., & Andriot, A. L., (2012), “That's what makes a woman”: Infertility and coping with a failed life course transition, Sociological Spectrum, 32, p226-243. [https://doi.org/10.1080/02732173.2012.663711]
• Lopata, A., Brown, J., Leeton, J., Talbot, J. M., & Wood, C., (1979), In vitro fertilization of preovulatory oocytes and embryo transfer in infertile patients treated with clomiphene and human chorionic gonadotropin, Fertility & Sterility, 34, p52-54. [https://doi.org/10.1097/00006254-197901000-00020]
• Lukse, M., & Vacc, N. A., (1999), Grief, depression, and coping in women undergoing infertility treatment, Obstetrics & Gynecology, 93, p245-251. [https://doi.org/10.1097/00006250-199902000-00017]
• Marcus, S. F., & Brinsden, P. R., (1999), Oocyte donation, In P. R. Brinsden (Ed.), A textbook of in vitro fertilization and assisted reproduction, p343-354, London, Parthenon Publishing.
• Matsubayashi, H., Hosaka, T., Izumi, S. I., Suzuki, T., Kondo, A., & Makino, T., (2004), Increased depression and anxiety in infertile Japanese women resulting from lack of husband's support and feelings of stress, General Hospital Psychiatry, 26, p398-404. [https://doi.org/10.1016/j.genhosppsych.2004.05.002]
• Massey, E., Kranenburg, L., Zuidema, W., Hak, G., Erdman, R., Hilhorst, M., & Weimar, W., (2011), Altruistic donation to strangers: Donor motivation and interpersonal values, In W. Weimer, M. A. Bos, & J. J. Busschbach (Eds.), Organ transplantation: Ethical, legal and psychosocial aspects—Expanding the European platform, p370-377, Lengerich, Pabst.
• Nachtigall, R. D., Becker, G., & Wozny, M., (1992), The effects of gender-specific diagnosis on men’s and women’s response to infertility, Fertil Steril, 57(1), p113-121. [https://doi.org/10.1016/0020-7292(92)90832-4]
• Newton, C. R., (2006), Infertility counselling: A comprehensive handbook for clinicians, New York, Parthenon Publishing.
• Olshansky, E. F., (1987), Identity of self as infertile: An example of theory-generating research, Advances in Nursing Science, 9, p54-63.
• Péloquin, K., Brassard, A., Arpin, V., Sabourin, S., & Wright, J., (2017), Whose fault is it? Blame predicting psychological adjustment and couple satisfaction in couples seeking fertility treatment, Journal of Psychosomatic Obstetrics & Gynecology, 39(1), p1-9. [https://doi.org/10.1080/0167482x.2017.1289369]
• Peterson, B. D., Newton, C. R., Rosen, K. H., & Schulman, R. S., (2006), Coping processes of couples experiencing infertility, Family Relations, 55, p227-239. [https://doi.org/10.1111/j.1741-3729.2006.00372.x]
• Peterson, B. D., Pirritano, M., Block, J. M., & Schmidt, L., (2011), Marital benefit and coping strategies in men and women undergoing unsuccessful fertility treatments over a 5-year period, Fertility and Sterility, 95, p1759-1763. [https://doi.org/10.1016/j.fertnstert.2011.01.125]
• Ramezanzadeh, F., Aghssa, M. M., Abedinia, N., Zayeri, F., Khanafshar, N., Shariat, M., & Jafarabadi, M., (2004), A survey of relationship between anxiety, depression and duration of infertility, BMC Women's Health, 4, p9, Retrieved from http://doi.org/10.1186/1472-6874-4-9. [https://doi.org/10.1186/1472-6874-4-9]
• Rauprich, O., Berns, E., & Vollmann, J., (2011), Information provision and decision-making in assisted reproduction treatment: Results from a survey in Germany, Human Reproduction, 26, p2382-2391. [https://doi.org/10.1093/humrep/der207]
• Reis, S., Xavier, M. R., Coelho, R., & Montenegro, N., (2013), Psychological impact of single and multiple courses of assisted reproductive treatments in couples: A comparative study, European Journal of Obstetrics & Gynaecology and Reproductive Biology, 171, p61-66. [https://doi.org/10.1016/j.ejogrb.2013.07.034]
• Schmidt, L., (2006), Infertility and assisted reproduction in Denmark, Danish Medical Bulletin, 53, p390-417.
• Schmidt, L., Holstein, B., Christensen, U., & Boivin, J., (2005), Does infertility cause marital benefit? An epidemiological study of 2250 women and men in fertility treatment, Patient Education and Counselling, 59, p244-251.
• Shih, K. Y., & Pyke, K., (2015), Seeing mothers-in-law through the lens of the mothering ideology: An interview analysis of Taiwanese, Taiwanese American, and Mexican American daughters-in-law, Journal of Family Issues, 37, p1968-1993.
• Smith, J. A., (2011), Evaluating the contribution of interpretative phenomenological analysis, Health Psychology Review, 5, p9-27. [https://doi.org/10.1080/17437199.2010.510659]
• Smith, J. A., & Osborn, M., (2008), Interpretative phenomenological analysis, J. Smith (Ed.), Qualitative psychology: A practical guide to research methods, p53-80, London, SAGE.
• Smith, J. F., Walsh, T. J., Shindel, A. W., Turek, P. J., Wing, H., Pasch, L., & Katz, P. P., (2009), Sexual, marital, and social impact of a man's perceived infertility diagnosis, The Journal of Sexual Medicine, 6, p2505-2515. [https://doi.org/10.1111/j.1743-6109.2009.01383.x]
• Sun, T. Y., & Lee, G. H., (2000), Psychosocial response of Chinese infertile husbands and wives, Archives of Andrology, 45, p143-148. [https://doi.org/10.1080/01485010050193913]
• Tanturri, M. L., & Mencarini, L., (2008), Childless or childfree? Paths to voluntary childlessness in Italy, Population and Development Review, 34, p51-77. [https://doi.org/10.1111/j.1728-4457.2008.00205.x]
• Ticinelli, I., (2012), The psychosocial impact of infertility on African American women: A grounded theory study, (Unpublished doctoral dissertation), Fordham University, New York, Retrieved from https://fordham.bepress.com/dissertations/AAI3518884.
• Tsui, E. Y. L., (2014), Reproductive health and infertility services, In K. W. Tong, & K. N. K. Fong (Eds.), Community care in Hong Kong: Current practices, proactive-research studies and future directions, p145-165, Hong Kong, City University of Hong Kong Press.
• Van Gulik, R. H., (1995), Sexual life in ancient China: A preliminary survey of Chinese sex and society from ca 1500 BC till AD 1644, Shanghai, Shanghai People’s Press, (In Chinese).
• Wang, W., & Tang, S., (2004), The spring and autumn annals book of the ram annotated, Shanghai, Shanghai International Press, (In Chinese).
• West, C., & Zimmerman, D. H., (2009), Accounting for doing gender, Gender and Society, 23, p112-122. [https://doi.org/10.1177/0891243208326529]
• Whiteford, L. M., & Gonzalez, L., (1995), Stigma: The hidden burden of infertility, Social Science and Medicine, 40, p27-36. [https://doi.org/10.1016/0277-9536(94)00124-c]
• Williams, M. J., McManus, F., Muse, K., & Williams, J. M. G., (2011), Mindfulness‐based cognitive therapy for severe health anxiety (hypochondriasis): An interpretative phenomenological analysis of patients’ experiences, British Journal of Clinical Psychology, 50, p379-397. [https://doi.org/10.1111/j.2044-8260.2010.02000.x]
• World Bank Group, (2018), Fertility rate, total (births per woman), Retrieved from https://data.worldbank.org/indicator/SP.DYN.TFRT.IN?locations=CN.