This study examined fertility treatment decision-making participation preferences among Chinese women following a recent unsuccessful IVF cycle. Most participants prefer to share decision-making than handing over this task to their doctors or make decisions themselves. In agreement with Deber and colleagues [16] the preference for sharing rather than handing over decision-making tasks was higher for a specific health condition (i.e. fertility treatment) than a general health condition (i.e. mild chest pain). Previous studies have reported that couples experiencing infertility are keen to search for treatment-related information and share this with their healthcare professionals in order to maximizing the chances of successful treatment [4, 32]. As our participants were not completely new to IVF, they were likely to be more knowledgeable about fertility treatment than a dubious chest pain.

Despite the greater power distance between patients and healthcare professionals that characterises Chinese culture compared to Canadian culture [33], we documented a greater preference for Shared roles (and a lower preference for a Passive role) in our Hong Kong sample than in the Canadian study. In fact, no Canadian participants chose Autonomous roles, while a minority of our participants did so. While a direct comparison was not feasible, our participants were in fertility treatment for an average of 4.0years (+/2.5) and had completed at least one IVF cycle, while their Canadian counterparts were in treatment for 2.3years (+/2.6) only. The longer duration of fertility treatment may have led to greater self-efficacy in sharing treatment decision tasks. However, the effect of previous clinical experience (e.g. years of infertility, years of ART) did not result in a significant difference in preferences in the Hong Kong sample, after controlling for other demographic, clinical and well-being factors. Nonetheless, our findings serve to demonstrate the variety of possibilities regarding cultural differences in healthcare decision-making and the multi-factorial nature of patients preferences.

Our findings reveal several demographic and clinical factors related to decision-making participation preferences in the doctor-patient relationship. First, in agreement with previous studies, participants with a religious affiliation tended to be more passive than those without a religious affiliation, possibly due to a greater tendency to trust authorities [34]. Due to the small cell sizes and the lack of existing literature on the effect of different religions on the fertility experience of the Chinese population, by the principle of parsimony, we only dichotomized the sample into those who reported and those who did not report a religious affiliation. However, future research may explore the nuances of the impact of different religions on the experience of fertility treatment among East Asian patients. Passivity in treatment decision-making was also related to the diagnosis of secondary infertility, rather than primary infertility. Participants diagnosed with secondary infertility may have greater difficulties making sense of their current fertility problems as they have previously achieved a clinical pregnancy, irrespective of the outcome (live birth, ectopic pregnancy, or miscarriage). Hence, with greater uncertainty and complications regarding their reproductive potential, they may exhibit a higher tendency to rely on healthcare professionals for treatment decision-making. Likewise, relative to women confronting infertility of mixed causation, women with female factor only infertility tended to be more autonomous in fertility treatment decision-making. This greater autonomy could have been encouraged by the greater certainty of attributing the cause of infertility to oneself, and subsequently greater perceived responsibility for the condition and its treatment.

Nonetheless, in spousal relationships, nearly half of our sample preferred to hand over both PS and DM to their husband. The percentage of participants who preferred to share decision-making tasks dropped from 92% in the doctor-patient relationship to 52% in the spousal relationship. Being autonomous, however, remained a minority choice. The options postulated to be theoretically implausible by Deber and colleagues [16] were rare in the spousal context.

Several factors were related to the tendency to hand over rather than share decision-making tasks in the spousal relationship. Having controlled for the womans age, a higher husbands age was related to a greater tendency to hand over rather than share decision-making tasks. The larger spousal age gap, especially when the husband is the older spouse, may have enlarged the power imbalance between a couple, leading to a greater preponderance of the husbands view as regards infertility and its treatment. This could be particularly pertinent in Chinese culture where the child bears only the paternal family surname and bloodline. Higher anxiety in women was also related to a greater tendency to entrust the decision-making tasks to their husband. Anxiety may have fuelled a womans wish for her husband to shoulder the psychological burdens of decision-making.

In contrast to the shared decision-making model [7], according to which patients enjoy better adjustment with active engagement in the treatment decision-making process, in this study Passive roles in both the doctor-patient and spousal relationships were related to higher marital satisfaction. Our study cannot clarify the direction of causality between marital satisfaction and decision-making participation preferences. However, several explanations are possible. First, entrusting the tasks to a knowledgeable outsider, such as a doctor, may avoid relational conflicts, especially when the couple are divided in their views over infertility and its treatment. Active involvement or even handing over key tasks in treatment decision-making to the husband may foster mutual trust and commitment and enhance relational quality in fertility treatment where husbands are often side-lined [35]. Hence, handing over the decision-making tasks to doctors and husbands may enhance relational quality. On the other hand, higher relational quality may increase the tendency to hand over decision-making tasks to doctors or husbands. Inviting the husband to PS and DM requires pre-established trust that the couple are on the same page and share similar views about treatment.

Our participants had experienced a recent unsuccessful IVF cycle. Relinquishing treatment decision-making to a trusted partner at this emotionally difficult time may reduce the pressure on the woman on the one hand, but is also a precarious move on the other, especially if the husband does not share his wifes views or knowledge about the treatment. Thus, among couples where the wife has chosen to hand over PS and DM, there could be a high level of consensus and pre-established trust in fertility-related issues, which are impetuses for harmonious relationships. Higher marital satisfaction may also reduce the womans distress and enable her to place greater trust in and be more open to suggestions from the healthcare team. Hence, a high level of marital satisfaction could be the antecedent for handing-over decision-making tasks to husbands and doctors, rather than its consequence. Fertility treatment decision-making epitomizes how marital and doctor-patient relationships interact and influence each other. Future studies are encouraged to examine the interactions of these relationships in a contextualized and dynamic manner.

In addition to self-selection bias in recruitment, this cross-sectional study provides only a snapshot of the experience of women in IVF treatment and cannot infer the direction of causality. Decision-making participation preferences could change with increasing knowledge, treatment experience, and relationships with other decision-makers such as doctors and a partner. Future studies should adopt a longitudinal approach to examine changes in participation preferences and clarify the antecedents and consequences of these changes. We also only included women with experience of a recent unsuccessful IVF cycle. Their decision-making participation preferences could be different from women who have not initiated treatment, are in active treatment or who have already terminated treatment. Lastly, this study investigated participation preferences from the vantage point of the women rather than actual participation of the women, their partners and doctors. Future studies should investigate the perspectives of partners and doctors and develop means to improve the congruence of actual and preferred participation of all parties.

Despite the complexity of treatment decisions, our findings highlight that in partnership with doctors, women were keen to find solutions to their fertility problems as well as weighing various treatment options to arrive at a decision they deemed the best for them and their families. Echoing European Society of Human Reproduction and Embryology (ESHRE) guidelines [36] on psychosocial care in fertility treatment, our findings underscore the importance of providing information and decisional support to patients before, during and after a fertility treatment cycle. Not only is factual information about the pros, the cons and what to expect from different treatment and non-treatment options (e.g., adoption) important, decisional support in weighing different factors in relation to the unique situation of the woman and relational dynamics is also vital. The ultimate decision in fertility treatment is usually a trade-off among multiple factors that tend to be rather idiosyncratic and sometimes contradictory, including physical burden, psychological distress, social and familial expectations, desires for a biological child, financial affordability, etc. [5, 37]. A previous German study found that fertility patients were not well equipped to make informed treatment decisions because of their overwhelming desire for a child and insufficient information about the psycho-social-economic costs of treatment [5]. Counsellors should pay particular attention to these tangible and intangible costs and desires, screen for psychological and relational distress using validated measures and offer appropriate emotional and decisional support to couples throughout their treatment journey.

Unlike many other health conditions fertility treatment is marked by its relational nature [19]. Our findings highlight the significance of husbands involvement in decision-making from the viewpoint of their wives, and the associations between participation preferences and marital satisfaction. Chinese couples often face enormous stigma for being childless from both paternal and maternal families [24]. A husbands involvement has been found to be pivotal both for his wifes and his own adjustment [23, 38]. However, most husbands feel alienated in fertility treatment as many procedures and decisions concern their wife only [35]. Men are often involved in a typical IVF cycle at two points only consenting to the treatment and providing a semen sample. Previous studies found that husbands tend to perceive themselves as a stoic emotional rock to support their wife, an agent exercising a rational veto and responsibility, and/ or a biological necessity to provide semen [20, 39, 40]. The supportive role aside, the mere fact of infertility could be emasculating [41]. Guilt is commonly experienced, especially when witnessing the physical and emotional duress experienced by their partner because of their shared desire for a biological child [22], and is particularly salient in cases of male-factor infertility [42]. The prospect of involuntary childlessness is daunting for many men who have long aspired to be a father [43]. Under such threats to virility, the pressure to be strong and masculine escalates, making disclosure of distress and help-seeking even harder [44,45,46]. Hence, patient enablement and counselling in fertility settings should include husbands whenever appropriate and possible. To start with, healthcare professionals should acknowledge the construction of treatment preference as a multi-factorial and dynamic interplay between intuitive and deliberative mental processes of both the woman and her partner. To achieve a couple-oriented approach, healthcare professionals should ensure husbands are offered adequate emotional, informational, and decisional support in fertility treatment. Fertility treatment has long been positioned as a feminine discipline. Nonetheless, future research should examine how much and in what ways husbands expect to be engaged in fertility treatment and its decision-making, as well as their understanding of infertility, desire for fatherhood and experiences in ART (e.g., sperm extraction, sperm donation, etc). The knowledge generated by this study will build the evidence-base for gender-sensitive and couple-oriented psychosocial support.

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Preferred problem solving and decision-making role in fertility treatment among women following an unsuccessful in vitro fertilization cycle - BMC...