Through decades of market development, Japan has evolved a unique system of in vitro fertilisation (IVF) delivery. Despite the lack of evidence supporting its efficacy, mild ovarian stimulation IVF (mild IVF) is widely implemented in Japanese clinics (Harada et al. 2023). These clinics specialise in mild IVF and natural-cycle IVF and do not provide conventional protocol treatments at all.^Footnote1 Mild IVF is framed as a ‘patient-friendly’ protocol in medical and public discourses. However, this claim concerning friendliness has rarely been examined through patients’ embodied experiences. The Japanese IVF landscape is situated within the context where the efficacy of IVF is low, with the second-highest number of registered IVF cycles (Adamson et al. 2023) and low success rates compared to other countries (Gleicher et al. 2019). In other words, on average, Japanese patients undertake more treatment cycles before they can take a baby home. Scholars have argued that this is primarily due to the prevalence in that country of mild and natural-cycle IVF (Kushnir et al. 2018). This development contradicts the expectations of intended parents regarding IVF treatment, as their sole aim is to bring a baby home as quickly as possible. As one form of the common IVF treatment protocol worldwide, mild IVF exists for substantial medical reasons, especially for those reacting intensely to hormonal stimulation medication and are at risk for side effects (Datta et al. 2021). In Japan, however, mild IVF is used beyond medical reasons. The Japanese assisted reproductive technologies registry data suggest that in 2007–2015, 49% were conventional IVF cycles, 22% were mild-stimulation IVF, and 29% were natural-cycle IVF (Kuroda 2021). This is not equally observed in other countries. Although national authorities rarely disclose statistics on differential ovarian treatment protocols, research shows that mild and natural IVF have limited 3% acceptance in the US (Kushnir et al. 2018), while only 1% of IVF cycles are unstimulated in the UK (Sunkara et al. 2016).^Footnote2

Mild IVF is significantly prevalent in Japan for decades because of multiple structural factors intersecting in medical, political, social and cultural aspects, including the medical communities’ concerns about novel reproductive technologies and ovarian hyperstimulation syndrome (OHSS), limited resources in IVF facilities, treatment costs and government subsidy design, existing social norms refraining medical intervention to reproductive activities, and more.^Footnote3 One crucial factor that provides the essential background for this article is that mild IVF is promoted by medical professionals as the patient-friendly choice (Ubaldi et al. 2007). In Japanese clinics’ promotion for mild IVF, it is presented not only as a treatment option, which allows intended parents to exercise autonomy and make efforts for their treatment, but this protocol is also presented as a treatment that cares for the maternal body, which could stimulate ‘natural’ fertility. For example, the most popular IVF in Japan is a mild and natural-cycle IVF clinic. This single facility implements 18,649 IVF cycles in 2018, treating an average of 550 patients daily (Kato 2018). These numbers are astonishing, even on a global scale. This clinic applies “more gentle, more natural” treatments, referring to mild and natural-cycle IVF. Their website states that their philosophies are helping patients to have a baby with as little physical burden as possible, believing in the patient’s “ninshin suru chikara” (ability to conceive), treating every egg retrieved with care and aiming for pregnancy with a minimum of medical intervention (Kato Ladies Clinic, n.d.). It accurately responds to those suffering from infertility, carving a path to hope, and hope is the essence of the thriving development of IVF technology (Franklin 1997). According to Gleicher et al. (2019), the adoption of the protocols utilised in this clinic was reproduced across Japan as early as 2002 and 2003 and quickly became the dominant protocol in Japan. Other clinics employ similar rhetorics to emphasise their caring for involuntarily infertile women through the ‘closer-to-nature’ approach (Minatomirai Yume Clinic, n.d.; Shinjuku ART Clinic, n.d.), which contests the overwhelming medicalisation of reproduction in conventional IVF. The clinics offer the mild approach as a moderate approach, which functions as an alternative to the conventional protocol by situating maternal bodies in a balanced position of medical intervention and natural conceiving ability. Medical research has also underlined these arguments by highlighting its lower cost, greater patient convenience, fewer side effects, and advantages associated with its ‘naturalness’. (Almind et al. 2018; Datta et al. 2021; Nargund and Fauser 2020).

Since mild IVF has high acceptance and clinical advantages among Japanese patients, it seems to be a good choice for IVF treatment. However, the essential question surrounding success rates and patient-friendliness remains. Extensive medical literature has researched the relative efficacy of the conventional and mild protocols, mainly focusing on comparisons of pregnancy and live birth rates; opinions differ on the size of the difference in efficacy. Endorsing perspectives indicate that the pregnancy rates and cumulative live birth rates of mild IVF are competitive with conventional IVF (Datta et al. 2021; Ferraretti et al. 2015; Kato et al. 2012). On the other hand, contradictory to these perspectives, clinical findings suggest that the higher number of oocytes retrieved under the conventional protocol increases the chance of achieving a successful live birth in IVF treatment (Beall and DeCherney 2012). For example, there was a 59.5% cumulative live birth rate for the group in which 16 or more eggs were collected and a 24.3% cumulative live birth rate for the group in which 4 to 9 eggs were collected (Jwa and Ishihara 2021). I do not attempt to evaluate the relative efficacy of the different protocols since this has already been extensively (though not conclusively) covered in medical research. Rather, this article aims to investigate claims about patient-friendly care in the light of women’s encounters with mild IVF treatment, given that dominant perspectives (medical knowledge) tend to serve their own interests and misinterpret such interests as universal (Anderson 2020). In Moser’s (2011) account, tracing “the interactions and exchanges between different communities, practices, and concepts” (p.717) conceptualises care in relational webs, illustrating the limits and ideologies embedded in the practices of care. Thus, in this article, I ask, is mild IVF a friendly protocol for Japanese women pursuing IVF?

I will focus on the practices in a crucial stage of IVF treatment, egg retrieval, to challenge the medical arguments of mild IVF as ‘friendly’ through women’s embodied experiences. Given that clinicians and prospective patients do not evaluate mild IVF purely based on per-cycle success rates,^Footnote4 I will answer the research question from two aspects of the experiences of egg retrieval: the treatment cycle required and the pain associated with egg retrieval operation. I chose the egg retrieval stage as the primary focus of my study because, firstly, the number of eggs collected in a single treatment cycle significantly impacts treatment experiences; it indicates the probability of advancing to the next stage and, ultimately, the likelihood of conception. Secondly, while the entire IVF journey is physically and mentally demanding, considerable stresses are particularly concentrated during the egg retrieval stage. Understanding the details encountered in egg retrieval assists in exploring how care is identified, formulated, and performed (Puig de la Bellacasa 2017) by the rhetorical frameworks and medical arrangements surrounding mild IVF in Japan. Furthermore, I question whether the care assembled in mild IVF practices is for women. Instead, it cares for the reproductive bodies and cells. The care rhetoric underpinning mild IVF in Japan demonstrates how care selectively organises and disciplines the bodies (Martin et al. 2015).

Contemporary medical technology developments intersect with the progress of the healthcare system, supported by the evidence-based movements in the governance of medical practices (Faulkner 2008). Mild IVF was present in the early days of IVF but went largely unnoticed, only emerging in clinical research due to concerns surrounding OHSS in the 2000s (Branigan and Estes 2000) as the evidence-based solution to improve IVF treatment. Its simplicity and low risk have been the primary advantages in the clinical evaluation of IVF stimulation protocol choice, ensuring that the concept of ‘patient-friendliness’ remains central to medical discourse. However, since the core of IVF treatment is still to successfully bring home a healthy baby, the efficacy of mild IVF is still the focus of clinical research. Many arguments in favour of mild IVF suggest that pregnancy rates and cumulative live birth rates with mild IVF are competitive with conventional IVF, leading to the view that mild IVF should be introduced to all patients (Blumenfeld 2015; Datta et al. 2021; Ferraretti et al. 2015; Kato et al. 2012; Nargund and Fauser 2020). The others specify the protocol advantages in reducing treatment burden and treating those with special needs. For example, mild IVF reduces the incidence of OHSS (Groen et al. 2013) and treatment costs (Mukherjee et al. 2012) and can be a beneficial option for women who respond unsatisfactorily to conventional ovarian stimulation methods (Montoya-Botero et al. 2021; Pantou et al. 2021). Although there is much clinical research with conflicting conclusions, showing that the efficacy and advantages of mild IVF are controversial, the core argument of its patient-friendliness has been repeatedly emphasised in clinical research. Still, the perspective of examination focuses on ‘clinical evidence’ rather than women’s embodied experience.

In the past decades, scholarship has been answering the question of what patient-centred IVF care is. From a governance perspective, research finds that accountability is established in the IVF sector in Western countries (Thompson 2005), or that health statistics organise the care infrastructure for IVF implementation in East Asian countries (Wu et al. 2020). These governance developments affected the clinical practices and treatment experiences of IVF technology. Gerrits (2016) portrays the aspects that formulate patient-centred practices in the Dutch context, including transparent frameworks in regulations, guidelines, and daily clinical operations. Fertility patients desire to be treated as individuals who are cared for by both system factors and human factors. including well-coordinated information and treatment process, good relationship with fertility clinic staff, affordable or reasonable costs, physical comfort, involvement from male partner and family, and emotional support (Dancet et al. 2010; Inhorn et al. 2018) and coexist with sociocultural norms and expectations on family life through the pursuit of IVF treatment (Kvernflaten et al. 2023). Research on add-on innovations in fertility treatment analyses how neoliberal market mechanisms use medical knowledge to shape hope and care (Perrotta 2024; Perrotta and Geampana 2021), which circles back to the analytical attention of the intertwined relationship between evidence-based medicine, regulation, and the commercialisation of fertility. In Gerrits’s (2016) reflection, the inquiry to patient-centredness in medical settings is fundamental and can lead to better patient–doctor relationships, while it could also risk intensifying the medical gaze on IVF patients and normalising the burdens of IVF. In my point of view, this is where the importance of examining mild IVF lies.

When research examines IVF technology as a whole and investigates how this technology can be patient-centred, the medical constructs underpinning each step in IVF implementation are not challenged. My following analysis demonstrates that the establishment of IVF technology relies on legitimating the medical knowledge and practices involved in the treatment, where the meaning of body and reproduction are produced and reproduced constantly to counter the fact that IVF has a high failure rate. I approach Japanese mild IVF practices from a care perspective, sensitive to the embodied experiences underpinning the technology, reflecting how care organises, classifies, and disciplines bodies through selective attention to specific lives or phenomena (Martin et al. 2015). The care rhetoric underpinning mild IVF practices also demonstrates the ontological ambivalence of care (Mol 2008; Puig de la Bellacasa 2017) and reproductive technologies (Franklin and Roberts 2006), which reproduces what it challenges. The focus on care and patient-friendliness in mild IVF represents the politics and knowledge supporting the moral aspirations within care (Martin et al. 2015).

Studying care further challenges the normalisation of care discourses and practices by contrasting what constitutes good care and what is considered improved in medical settings (Pols 2008). Similarly, Lydahl (2021a, b) questions the standardisation of measuring care in the evident-based healthcare system where form-based assessment cannot capture the nuance in care practices and the importance of doing ‘nothing’ in everyday care activities. These examples demonstrate that unpacking the formulation of care does not assess which is superior or inferior; the aim is to illustrate the politics, ethics, and norms that underpin everyday care practice. The attention to care does not answer where technoscience should go (Martin et al. 2015). Instead, this article explores the ontological ambivalence of care.

The data collection was conducted between December 2020 and February 2023 amid COVID-19 outbreaks and national lockdowns; therefore, the research design was highly dependent on remote means. I conducted in-depth email interviews with 32 women who underwent IVF treatment in Japan and reviewed their blog posts, along with eight interviews via Google Meet with medical professionals.

The age distribution of the women participants is slightly older than that of the overall IVF patient demographic characteristics in Japan,^Footnote5 with an average of 39. 53% of the participants were aged 40 years or older. The total duration of receiving IVF treatment ranges from two months to six years. About one-fourth of the participants had undertaken IVF treatment for over three years. The number of egg retrieval cycles experienced by the interviewees varied greatly, ranging from one cycle to more than 30 cycles. The average number of treatment cycles participants experienced is six egg retrieval cycles and 4.6 transfer cycles. Over 80% of the participants have experienced mild IVF cycles. At the end of participation, half of the participants were still receiving treatment, and over 80% had not yet had a child. The key characteristics of the participants are presented in Table 1.

The interviews were semi-structured (see the question list in Appendix 1). To promote thorough responses, each email included only three questions. The number of replies which participants gave ranged from three to 25. A total of 280 emails were received. One of the essential advantages of email interviews, particularly helpful during a global pandemic, is the ability to conduct asynchronous interviews, where participants can respond to questions at their convenience, with time and space (Ratislavová and Ratislav 2014). In addition to providing flexibility for participants (Dahlin 2021; Hawkins 2018), email interviews help capture thoughtfully considered and precisely written narratives (James 2007). However, this feature means that the timing of responses was unpredictable (Fritz and Vandermause 2018). While many participants were enthusiastic to share their experiences, unforeseen events in their lives, along with work and family obligations, prevented some from replying in detail or responding promptly. Additionally, participants could withdraw from interviews at any time by simply stopping their replies (Fritz and Vandermause 2018), which has impacted the data collection for this research. Four participants withdrew during the email interviews, and some interviews were lengthy, lasting up to twelve months. Research indicates that recruiting participants through email interviews may be constrained by their internet access, proficiency in using it, and ability to communicate via email (Ratislavová and Ratislav 2014), which carries implications for this study. The demographic characteristics of participants suggest that the recruitment process is likely to attract individuals who are highly educated, have higher incomes, and are more comfortable or adept at communicating online.

The data analysed in this article also include participants’ blog posts written before December 2021. Out of 32 participants, 15 consented to the use of their blog content. The number of articles in a single blog ranged from 20 to over 800. Blog posts are unlike email interviews. Participants select specific topics they wish to write about, sharing information not only for the research project. While the content may be broad, many posts contain information central to this article, including experiences with various treatment protocols and accounts of treatment challenges.

Interviews with medical professionals were straightforward and aimed to clarify the connotation of technology implementation and confirm the actual IVF treatment practice in Japan. The questions were more structured than those for women. I outlined seven groups of questions regarding their practices and choices of ovarian stimulation methods (see Appendix 2). Interviews were conducted on Google Meet and lasted between 30 min and one hour and 40 min. Table 2 presents key information about the medical informants interviewed.

All interview materials and blog content are in Japanese; they were translated into English by the author during the analysis. I employed thematic analysis (Fugard and Potts 2019), following the six stages of analysis outlined by Braun and Clarke (2006). Several themes were identified in the larger project; the two themes analysed here address the research question posed by the article. The ethical issues regarding confidentiality and cyber security (Hawkins 2018; Salmons 2014) were addressed through preventive measures, including the use of encrypted platforms and file encryption. The research proposal has been evaluated by the Ethics and Risk Assessment for Research Committee in the author’s affiliated institution. I adopted pseudonyms in this article, each referring to a unique individual.

IVF treatments involve repeated clinic visits. Attending these appointments has considerably disrupted women’s daily lives, especially for those who are in employment (Brod et al. 2009). One feature of mild IVF that has been promoted as patient-friendly is the reduced number of necessary clinic visits due to the smaller volume of medications and its different modes of administration (Almind et al. 2018). Standard clinical practices confirm this; for example, Japan’s most popular mild IVF clinic claims that mild IVF requires two to four clinic visits per egg retrieval cycle, compared with three to six visits per cycle when more medications are used (Kato Ladies Clinic n.d.). However, evidence from Japanese women’s experiences demonstrates a more complicated picture. Two critical encounters in an egg retrieval cycle affect their perceptions of a patient-friendly treatment: treatment scheduling and the number of cycles required, which sheds light on the purposes and values related to the practice of care (Mol et al. 2010).

In the Japanese context, the first examination for an egg collection cycle occurs on the second day of the menstrual cycle. The standard practice involves drawing blood and examining the hormonal index, which primarily indicates the follicle growth condition of the cycle. Additionally, an ultrasound is performed to ascertain how many follicles can be observed at this time. Participants reported that, depending on their physical conditions and the doctor–patient relationships in different clinical settings, the doctors determine or consult with them regarding which protocol to use and the medication dosage.^Footnote6 The significant difference starts here. Table 3 compares the standard treatment schedule for a user with a 28–30 day menstrual cycle in an egg retrieval cycle in mild IVF and conventional IVF published by Japanese clinics; notably, mild IVF clinics advocate that it requires fewer clinic visits.

However, there was no definitive agreement on this point from my participants’ experiences. I asked them how often they went to the clinic during treatment cycles. It appears that, in practice, three to four clinic visits before egg retrieval were the average regardless of the protocol utilised. To illustrate, I present treatment schedules reported by two participants who only experienced mild or conventional IVF. For Miyu, who had a very low dosage mild IVF cycle, this schedule entailed:

DAY 3 Examination: Started to take one pill after dinner every day, 50mg.

DAY 8 Examination: Tracked follicle growth. Continue to take pills.

DAY 11 Examination: Follow up on follicle growth and decide on the schedule for egg collection.

DAY 13 Egg retrieval: Six eggs were retrieved.

DAY 15 Consultation: Confirmation of fertilisation result.

Mako, who had only engaged in conventional IVF, described her schedule for an egg retrieval cycle:

One visit between D2 and D5 after the start of menstruation. One visit on around D10. One visit on D12. Egg retrieval on about D14. Post-ovulation examination at about D25 (to check for swelling of the ovaries, etc.)

Miyu and Mako each underwent a similar number of clinic visits, and the reasons for these visits were similar, monitoring ovulation, despite having undertaken different protocols. In particular, women undergoing mild IVF do appear to be called in for one or more interim scans between Days 2 and 12 to monitor the growth of follicular. In these cases, at least, women’s experiences indicate that the frequency of clinic visits did not differ between the two protocols. This was reflected in the experiences of other participants, indicating that, in general, there are only minor, if any, differences in the number of clinic visits required.

In addition to the number of clinic visits, my research revealed insights into practical issues in the way treatments are scheduled that counter the claim that, in this respect, mild IVF is a patient-friendly protocol. Women who had experienced mild IVF were often sharply critical of scheduling arrangements, mentioning that mild IVF appointments were often highly inconvenient. Some noted sudden and frequent requests to visit the clinic because an interim scan had indicated that ovulation was about to occur; they often faced great stress at these times, having to decide between asking for an abrupt day off from work or bearing the risk of missing the egg retrieval window. Some participants who had experienced both mild and conventional IVF commented that this lack of flexibility appeared to be a particular feature of mild IVF clinics. Kana depicted these mild clinics as “clinic-oriented”:

Treatment is standardised so that the same decision is made no matter which doctor you see. The treatment is clinic-oriented rather than patient-oriented. Patients who suit their methods are successfully treated, and those who do not are discarded.

My interviews with doctors helped shed light on this matter. Dr Akutsu noted that the primary challenge in scheduling mild IVF treatments is that it is more difficult to control than conventional IVF. Patients and doctors must be ready for egg retrieval at any time:

Predicting the condition and number of eggs is difficult. Therefore, some clinics ask patients to come every two days if they don’t fully know the growth of the eggs or if the dosage is not suitable. This is a great burden for patients.

Dr Yokota explained why participants may perceive mild IVF as a less flexible approach:

Conventional IVF is easy to control. So, for example, even if you have a small number of staff or if you have a holiday somewhere, you can still do egg retrieval. […] It is challenging to perform mild IVF in good conditions unless the facility has a certain level of staffing because the equipment must be ready for egg retrieval at any time.

Dr Yokota further acknowledged that with mild IVF, patients must adapt their personal schedules to the treatment:

Yokota: It depends on the patient’s schedule. Sometimes, their schedule is a bit difficult to adjust; in mild IVF, it might cause issues.

Me: Do patients have to adjust their schedule to get the good condition egg?

Yokota: Yes, they need to do this.

These discussions with physicians were significant as they highlighted that, to some extent, women must endure inconvenience when undergoing mild IVF. This did not reflect a lack of consideration by clinics; rather, it arose primarily from factors intrinsic to the mild IVF method, such as less predictable ovulation and a higher likelihood of cycle cancellation.

Cycle cancellation refers to an IVF cycle that is initiated but does not proceed to the transplant stage. An analysis of the Japanese IVF registry statistics from 2014 to 2015 indicates that the number of cancelled cycles was generally higher for stimulation methods that retrieved fewer eggs, namely mild IVF and natural-cycle IVF (Jwa and Ishihara 2021). More clinical research has concluded that the limitation of the mild approach in IVF is the relatively high cycle cancellation rate (around 15–20%) (Revelli et al. 2011; Verberg et al. 2007). According to the National Institute for Health and Care Excellence guidelines, a complete cycle of IVF includes one episode of ovarian stimulation and the transfer of any resultant fresh and frozen embryos (NICE 2013). Therefore, cycle cancellation at the very first stage of IVF treatment, meaning that there is no chance even to start egg retrieval, implying that they have to undergo repeated attempts, brought tremendous disappointment and self-doubt for my participants. Momoka, for instance, had a mild IVF cycle cancelled before egg retrieval. She reflected in detail on what she could do to improve her next cycle, from changing her lifestyle, what food she should eat and what supplements she should take. This is not only a review of the treatment contents but also a review of whether one is qualified and doing enough to pursue reproduction. The mild approach, based on the premise of sacrificing women’s autonomy over the treatment, essentially intensifies the monitoring of the reproductive body.

A well-known Japanese IVF doctor publicly criticised ‘more natural’ mild IVF: “It is not natural at all. The number of egg retrievals increases dramatically. It is natural in that it does not use medication, but it is not natural in that it involves a lot of egg retrieval” (Matsubayashi 2016). This statement sharply points out the contradictions in the practice of mild IVF. Several of my interview participants also voiced concerns. For instance, Saki expressed the following critique of mild IVF:

I am against mild IVF and natural cycles. […] I think it is inefficient. The amount of medication is indeed less, and it may be friendly on the body and financially. Still, the number of eggs that can be retrieved is fewer, so it’s likely to be repeated many times, and as a result, I don’t think it’s kind to the body or the wallet.

Repeated egg retrieval cycles not only indicate that patients need to undertake medications again but also indicate more clinic visits and scheduling between work, treatment, and daily life, which have been reported to provide or raise substantial stress for participants.

Unfortunately, these issues are not explained in the information given to women, and none of my participants appeared to be aware of them before undertaking mild IVF. It remains the case that depicting mild IVF protocols as patient-friendly in terms of coordinating with patients may, in reality, largely overlook factors that are truly important to patients. Mild IVF may be less physically demanding than conventional IVF, as it requires fewer medications or injections. In practice, however, it requires patients to be flexible in terms of treatment schedules and be constantly ready to accept appointment times and cycle cancellations at any time. Furthermore, mild IVF clinics direct the attention of cycle cancellation and success rates to individual physical diversity (Kato Ladies Clinic n.d.) and emphasise patients’ responsibility to maintain a healthy lifestyle and be prepared for treatment at all times (Funin Info n.d.).

The unpredictability and higher possibility of cancellation in mild IVF technology are obscured by the selective performance and presentation of patient care (Martin et al. 2015). On paper, mild IVF clinics stress their patient-friendliness on smaller volumes of medications and easier administration process of treatment. However, the technical factors involved in mild IVF treatments render monitoring more challenging for clinics and, in turn, women. It is distressing to repeat the cycle from hope to disappointment and remain positive while undertaking stimulation medications; it is also physically demanding to a certain extent in any protocol, the patient-friendly one or the standard one. As Mio noted, “Either way, the days leading up to egg retrieval are tough”. No protocol is easy on women’s bodies when extra hormones are administered, and the likelihood of more cycles must always be taken into account. This analysis has shown that the chosen treatment protocol may not achieve the intended or promised effect, reflecting the assembly of care practices and knowledge involves inherent conflicts. (Puig de la Bellacasa 2011).

For my first child, before going to A Clinic, every treatment and examination I had in the previous clinic was too painful. So, I never felt any pain in A Clinic for pelvic examination, egg retrieval, or embryo transfer. But it seems I have forgotten there are at least minimal pains. This egg retrieval was painful and scary.

Participant Yama documented the pain associated with egg retrieval on her blog. She decided to embark on IVF treatment for a second child when her first child was around one year old. She got pregnant with the first child at A Clinic, utilising mild IVF and was satisfied with the treatment in A Clinic. Before A Clinic, she underwent conventional IVF treatment, which involved considerable pain, leading to a decrease in Yama’s perception of pain at A Clinic. However, upon restarting treatment at the same clinic this time, the pain grew intense and unbearable. Yama’s depiction illustrates that pain is a significant embodied experience in IVF, one that cannot be fully imagined until it is encountered and is highly dependent on context. In Gerrits’s (2016) ethnographic work, she presents detailed narratives of the physical and psychological burdens associated with IVF treatment, encompassing the stages from injections and egg retrieval to embryo transfer and miscarriage. My data suggest findings similar to those of Gerrits, indicating that the experiences of pain, side effects, and other physical effects from IVF are, to some extent, contextual. On one day or cycle, women may feel dreadful, while on another, they may feel completely different. However, in contrast to Gerrits’s findings, which emphasise the significance of well-informed treatments and the participation of male partners at every stage of IVF, my participants depicted a rather lonely and neglected experience, particularly regarding the egg retrieval procedures. At the start of my research, I was astounded by which women had been surprised to find that their clinic only provides minimal options for anaesthesia during egg retrieval procedures and how painful and frightening they found these experiences. These observations prompted me to discuss pain control for egg retrieval with participants. Regardless of the protocol used, most participants experienced pain during egg retrieval. The level of pain differed between women and between cycles, but still, it remained a significant shared experience. The crucial factor concerning mild IVF practice is that, in reality, women receive less pain relief during mild IVF treatments than in conventional IVF, and this arises from a nuanced interaction between medical facilities and patients.

A range of pain relief protocols for egg retrieval are available, including general anaesthesia (either by injection or inhalation), local or regional anaesthesia (through injections into the vaginal wall or epidural or spinal block), oral analgesia, and sedation with or without local anaesthesia (Vlahos et al. 2009). General anaesthesia carries some risks in all contexts (Jenkins and Baker 2003) and may affect the pregnancy rate in IVF (Gonen et al. 1995; Kwan et al. 2018; Sharma et al. 2015); therefore, it is reported that the most commonly used pain control in IVF is sedation (Jain et al., 2009; Yasmin et al. 2004). General IVF clinics in Japan now provide options for pain control in egg retrieval. This would normally be conscious sedation, in which patients can breathe alone but are asleep or (almost) entirely unconscious. Japanese mild IVF clinics also state that they provide options for pain control and that it is the patient’s autonomous decision to have anaesthesia or sedation. Nonetheless, the use of pain management in Japanese IVF clinics remains limited. Most assisted reproductive facilities do not have an anaesthesiologist on staff (Harada et al. 2023), and many women are given only local anaesthetics administered by intramuscular injection, suppositories, or oral analgesics. When injectable sedation is used, it tends to be used conservatively and at relatively low doses. Furthermore, although general anaesthesia is hardly used in current Japanese IVF procedures, the words used in describing all forms of pain control in Japanese IVF clinics are usually “anaesthesia” rather than “sedation”, leaving a space of confusion for patients. In my following discussion, I also use “anaesthesia” to describe pain control during egg retrieval surgery in Japan, rather than “sedation”. This is mainly to highlight the Japanese context and avoid confusion caused by repeated replacement of words.

This general practice of much more sparing use of anaesthesia in reproductive activities in Japan is a result of the historical process of medicalising childbirth (see Shirai 2020). In Japan’s modern perinatal care system, the use of anaesthesia during childbirth is uncommon, with 6.1% of all deliveries utilising some form of anaesthesia in 2016. (Kurakazu et al. 2020). A common belief among women and doctors is that pain in labour enhances the mother- child bond (Kishi et al. 2011; Suzumori et al. 2021); however, institutional restraints have made pain control difficult to administer during labour. The reasons behind the low rate of pain relief are a shortage of obstetricians and anaesthesiologists, limited access to birth facilities, and the high costs of epidural anaesthesia (Maeda et al. 2019).

These cultural norms and institutional restraints have been reflected in IVF procedures. Intense bioethical debates accompanied the introduction of IVF in Japan. One group that resisted supporting IVF was anaesthesiologists (Yomiuri Shimbun 2007). The situation slowly shifted when IVF became more socially accepted. However, the initial dispute and the consistent sociocultural resistance to anaesthesia in reproductive activities means that many physicians remain actively opposed to, or ambivalent about, the use of anaesthesia in IVF. This is particularly the case with medical professionals working in the field of low-stimulation, low-intervention mild- and natural-cycle IVF, who have developed a discourse that validates cultural expectations of limiting medical intervention while simultaneously emphasising care for women and the reproductive body and is depicted as the safest approach to performing IVF (Kato et al. 2012). An article published by the leading doctor of a Japanese mild IVF clinic lists seven characteristics of their successful treatment approach, one of which was egg retrieval without anaesthesia (Kato 2018). The article explains that the number of mature follicles in mild and natural-cycle IVF is low; thus, the egg retrieval procedure can be performed swiftly. The author further emphasises the drawbacks of anaesthesia during egg retrieval, highlighting the potential for complications, increased costs and recovery time, and discomfort upon waking.

These contexts provide the foundation for framing limited anaesthesia as a means of caring for women’s bodies and further legitimise mild IVF. Although most clinics theoretically offer a range of choices for women, my participants indicated that, in practice, their options were restricted, with some expressing that they essentially had to choose between discontinuing mild IVF and enduring the discomfort of egg retrieval. My interviews overwhelmingly suggest that women simply follow the policy of the clinic they are attending. Momoka, highly knowledgeable about IVF procedures and later employed at an IVF clinic, shared her observations on Japanese IVF anaesthesia practices, illustrating the perspective that women often make choices significantly influenced by clinics rather than their own needs:

The pain of egg retrieval is more likely to be felt by those with a high follicle count. […] General anaesthesia is not a problem because you are asleep, but local anaesthesia is only injected into the vaginal wall and has no effect on the pain when the needle penetrates the ovary and sticks into the follicle. […] The pain is more intense when puncturing a follicle as small as 10 mm than when puncturing a larger follicle of around 20 mm. […] The choice of anaesthesia depends on the clinic’s policy, and if they say, ‘Most of our patients are done without anaesthesia’, many patients will choose the anaesthesia-free option, even if they are anxious. Conversely, there are clinics where general anaesthesia is the norm, whether it is one or 20 eggs.

Several other participants also mentioned discussions relating to the number of eggs to be harvested. Medical discourses argue that the pain level in egg retrieval procedures varies according to numerous factors, including the number of eggs being harvested (Singhal et al. 2017) and the needle size (Wikland et al. 2011). Many clinics, therefore, suggest that patients with an egg count below five can undertake egg retrieval without anaesthesia, which is a common scenario in mild IVF treatments. However, many women undertaking mild IVF felt that their pain was not taken seriously by the clinics. For example, Saki shared a challenging experience in a mild IVF egg retrieval cycle:

At my clinic, anaesthesia was recommended when the number of eggs retrieved was likely to be more than five. When the number of eggs retrieved was less than that, there was no anaesthesia. On my third egg retrieval, the number of eggs retrieved was expected to be high, so I asked the doctor if he wanted to anaesthetise me. The doctor replied, “You’ve had three cycles without anaesthesia, haven’t you? You will be fine without anaesthesia even if there are more eggs”. I believed him and went without anaesthesia, and it was incredibly painful.

Saori, who switched from conventional to mild IVF, asked about anaesthesia in her first examination in the mild IVF clinic. She had experienced pain in her previous conventional IVF cycle and expressed her worries about pain to her doctor:

I am very weak when it comes to pain. People say that compared to the pain of childbirth. […] I don’t like it when people tell me this when talking about pain in IVF. That’s not what I’m talking about. […] The doctor said that spray anaesthesia is like taking a rest; it doesn’t seem to make much sense. […] But I still do it, just in case. [The doctor said] if the pain is unbearable, he can refer me to another clinic, but there are only one or two people like that every ten years. So, almost no anaesthesia for this egg retrieval.

The doctor was not keen on providing options other than local spray anaesthesia. The dismissal of Saori’s feelings and the doctor’s reference to endurance meant she faced a dilemma. Without other options for anaesthesia, the choice she faced was to withstand the pain and take her chances with trying mild IVF or to give up the attempt entirely. Moreover, the reference to the cultural norm of women enduring pain during childbirth (“People say that compared to the pain of childbirth…”) served to convince her to disregard her bodily response to pain.

Some women I interviewed had been told that pain during reproductive activities is a cherished maternal experience, which may coerce them into avoiding pain control methods and potentially invalidate their encounters with pain during egg retrieval. Aiko shared her observations regarding anaesthesia in Japanese IVF:

You know, most clinics don’t let you have anaesthesia for egg retrieval. I think that’s sick. I asked other women, “Doesn’t it hurt? Doesn’t it feel scary?” They answered that giving birth is even more painful. “How can you be a mum if you can’t even bear this pain?”

The doctor–patient relationship in Japan is largely paternalistic (Ishikawa and Yamazaki 2005), and this has been reflected in negotiations over anaesthesia in mild IVF treatments. The interactions illustrated in the quotations above indicate that clinics’ administrative considerations may take precedence over women’s needs. In stark contrast to the patient-centred care discussed by Gerrits (2016), which indicated that prior information and preparation from the clinic helped to reduce negative experiences, the cases of my participants revealed that the pain associated with treatment was neither communicated in advance nor sufficiently acknowledged. The number of follicles observed in various protocols becomes the primarily clinical interpretation of a painful experience. It defines which kinds of pain should be dealt with or not, with little regard for women’s embodied knowledge. Care concepts are utilised to support limiting anaesthesia administration, and the centre of attention is the reproductive bodies rather than the female bodies. Pain may be a highly individualised experience, which is hard to translate into standardised practices. However, the evidence provided here illustrates that the conflict between patients and doctors is intensified by clinics’ institutional considerations, which were shaped together by the care claim of mild IVF and the norm of enduring pain.

Some participants described the pain experienced during egg retrieval as manageable. For instance, Momoka and Kana, both of whom underwent mild IVF, characterised egg retrieval as a “tolerable level of pain”. For various reasons, they each had only a few follicles per cycle, and throughout their numerous cycles, their doctors seldom suggested that they receive any anaesthesia. However, other participants described an excruciating experience with anaesthesia-free egg retrieval procedures during their mild IVF treatments. For example, Kaede said:

My current mental condition is that nothing pays off, accompanied by much money, time, and pain. […] The world is only kind to pregnant women, and no one cares for infertile people or just treats them like an inflammation wound. I am less involved with my friends. As for pain, the egg retrieval was particularly painful because the clinic I went to was anaesthesia-free. I paid hundreds of thousands of yen for a single egg retrieval, and 1 million yen for treatment over the course of six months. […] No matter how much money I paid, how much pain I endured and how hard I tried, the lack of results gnawed at my originally proud heart.

Kaede typically had only one or two follicles at a time, and from the perspective of mild IVF doctors, the associated pain was minimal. Nevertheless, Kaede needed to take a day off work to recover each time, making egg retrieval one of the most challenging aspects of her IVF treatment. Furthermore, her experience of pain was intertwined with persistent frustrations that exacerbated her negative views of the treatment. Pain in IVF is never a singular and isolated experience for women; it is the embodied representation of expectations and frustrations of the entire treatment process. During our discussion, Kaede had completed four cycles of mild IVF and was seeking a conventional IVF clinic. When I asked her about the advantages of conventional IVF, she replied, “The advantage is that you can collect many eggs at once without having to collect them over and over again, which may reduce the pain”. For another participant, Hikari had experienced over 30 episodes of egg retrieval, with dread lingering each time. The pain was vividly recalled by the frightening surgical scene, which deepened the memory of the suffering. It is a combination of fear and pain:

I had either no anaesthesia or local anaesthesia, but both were painful. Even with [local] anaesthesia, I had the sensation of something being done to me. And I could see the egg retrieval procedure from the lights in the operating theatre, which scared me.

It should be noted that a lack of anaesthesia is not unique to mild IVF – it is also not uncommon in Japan for conventional IVF egg retrieval to be done only with local or even no anaesthesia, and some participants also reported painful experiences with conventional IVF. Women’s experiences highlight the notably conservative approach to anaesthesia in reproductive medicine in Japan. Some women’s experiences, particularly those recounted in blogs, indicated an anticipation gap between patients and doctors. In certain IVF clinics, pain management seems only aimed at alleviating pain to a tolerable level rather than eradicating it entirely. Meanwhile, patients expect their pain to be controlled to the point where they feel minimal discomfort or none at all. This gap is also observed in the mild IVF settings. Research suggests that women tend to relativise the burdens of IVF by comparing them with the resources they have invested and the goals they aim to achieve while accepting the significant physical and mental tolls associated with IVF (Gerrits 2016). The participants in this study were indeed willing to ‘endure’ treatment (over 60% continue to receive treatment for 1–3 years, and 25% for more than 3 years); however, they seldom indicated that it affected them significantly less than they had anticipated, as demonstrated by Gerrits’s work. This might be because they receive less support from the medical system and their partners. Many participants’ clinics informed them that the pain was manageable or disregarded their request for pain relief. Additionally, not only did no husband of any participant enter the egg retrieval operating room with them, but even in the recovery room, no one was able to have their husband’s company, either because the husband did not take action or because the clinic did not encourage the husband’s participation and support.

Mild IVF practices pivotally reflect the sociocultural norms embedded in reproduction in Japan, mobilising medical discourses to sustain normative notions of reproduction. Such frameworks are consistent with existing local frameworks concerning the doctor–patient relationship and minimal medical intervention in reproductive activities, yet mild IVF broadens the spectrum by emphasising the delicate balance between patients’ natural fertility and technological interventions. This finding reflects the medical assemblage of care (Puig de la Bellacasa 2011) in Japanese IVF settings, where cultural norms are institutionalised as a form of good care. The story of mild IVF mobilises caring rhetoric, emphasising reduced medical interventions to depict an ideal framework for reproduction. Women’s bodily experiences have been substantially neglected.

The evaluation of patient-centeredness in IVF regards the treatment outcome and the process (Dancet et al. 2010; Gerrits 2016). In this article, I examine women’s embodied experiences in mild IVF treatment processes to scrutinise claims that advocate for mild IVF as patient-friendly. I contend that mild IVF protocols are not inherently as patient-friendly as many medical studies suggest. Mild IVF often comes with more treatment cycles, higher cancellation rates, and less predictable treatment processes. Its characteristic of reducing medication use leads to underestimation or neglect of pain resulting from egg retrieval procedures. These findings illustrate how medical constructions intertwine with and inform bodily experiences, social norms, and daily arrangements, unpacking and complicating the care ideology underpinning mild IVF practices.

There are several elements of the argument that mild IVF is patient-friendly. This article focuses on egg retrieval experiences and the expectation and assumption of endurance in medical practices and knowledge production. It is nuanced whether mild IVF is friendly in terms of the number of egg retrieval cycles needed to be able to have successful results. Clinical research suggests that mild IVF requires more cycles to be able to succeed, and women’s experiences reflect such arguments. However, clinics fail to present this information and stress the effect of individual physical differences, making patients remain hopeful for mild IVF. The cost and emotional stress of repeated cycles add another burden during the process. The resources participants put in one cycle are significant investments regardless of the protocol used. If it failed, it failed, and no protocol is friendly if it fails. The nuances demonstrated in this discussion indicate how care is selectively emphasised and the uneven knowledge distribution in Japanese IVF settings.

I also describe another aspect of mild IVF, which is not particularly patient-friendly; namely, that women often find themselves undergoing repeated egg retrievals with minimal or no anaesthesia. There are individual differences in pain tolerance, and clinics are beginning to provide more options, yet mild IVF is still advertised by highlighting its more natural approach that eschews anaesthesia. This reluctance towards anaesthesia aligns with a prolonged history of refraining from medical interventions in reproductive activities in Japan; however, at the end of the day, women want pain-free treatments. Women may forgo anaesthesia because it is not made available, because their concerns are not taken seriously, or because they face implicit or explicit pressure to tolerate pain. When anaesthesia is used, it may be administered in a conservative manner or at a conservative dosage. This study shows that the problem of pain during egg retrieval is not restricted to mild IVF but appears to be more common among women undergoing mild IVF. This is a problem that the medical community needs to take seriously and one that must be addressed before mild IVF can be considered truly patient-friendly.

Mol (2008) and Gerrits (2016) have contested that the logic of care in medical sites would not suffice only by informed consent, multiple choices, and gentle treatments. It is a process requiring continuous attention, coordination and understanding of (medical and social) limitations. The complexity of IVF treatment and underlying bioethics has rendered patients extremely easy to expose in isolation and overwhelmed by the dominance of advanced biomedicine and the medicalisation of their bodies (Gerrits 2016). Therefore, the establishment of patient-centred care in IVF treatment is highly nuanced. What is good care? There is no definitive answer to this question, but all the questions posed offer insights into developing quality care. When IVF medical communities across the globe start to promote a ‘tailor-made’ treatment approach (Tesarik and Mendoza-Tesarik 2022), providing multiple therapeutic choices that seemingly place patients’ needs at the centre, the analysis in this article highlights the awareness of how medical options are framed and implemented and how we can all be attentive in this dynamic adjustment process.