Systematic review of the impact of the COVID-19 pandemic on suicidal behaviour amongst health and social care workers across the world

BACKGROUND

The COVID-19 pandemic has had an impact on the mental health of healthcare and social care workers, and its potential effect on suicidal thoughts and behaviour is of particular concern.

METHODS

This systematic review identified and appraised the published literature that has reported on the impact of COVID-19 on suicidal thoughts and behaviour and self-harm amongst healthcare and social care workers worldwide up to May 31, 2021.

RESULTS

Out of 37 potentially relevant papers identified, ten met our eligibility criteria. Our review has highlighted that the impact of COVID-19 has varied as a function of setting, working relationships, occupational roles, and psychiatric comorbidities.

LIMITATIONS

There have been no completed cohort studies comparing pre- and post-pandemic suicidal thoughts and behaviours. It is possible some papers may have been missed in the search.

CONCLUSIONS

The current quality of evidence pertaining to suicidal behaviour in healthcare workers is poor, and evidence is entirely absent for those working in social care. The clinical relevance of this work is to bring attention to what evidence exists, and to encourage, in practice, proactive approaches to interventions for improving healthcare and social care worker mental health.

Assisted reproductive technology treatment and risk of breast cancer: a population-based cohort study

STUDY QUESTION

Is there an increased risk of breast cancer among women after ART treatment including ovarian hormone stimulation?

SUMMARY ANSWER

The risk of breast cancer was slightly increased among women after ART treatment compared to age-matched, untreated women in the background population, and the risk was further increased among women initiating ART treatment when aged 40+ years.

WHAT IS KNOWN ALREADY

The majority of breast cancer cases are sensitive to oestrogen, and ovarian hormone stimulation has been suggested to increase the risk of breast cancer by influencing endogenous oestrogen levels. Previous studies on ART treatment and breast cancer have varied in their findings, but several studies have small sample sizes or lack follow-up time and/or confounder adjustment. Recent childbirth, nulliparity and higher socio-economic status are breast cancer risk factors and the latter two are also associated with initiating ART treatment.

STUDY DESIGN, SIZE, DURATION

The Danish National ART-Couple II (DANAC II) cohort includes women treated with ART at public and private fertility clinics in 1994-2016.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women with no cancer prior to ART treatment were included (n = 61 579). Women from the background population with similar age and no prior history of ART treatment were randomly selected as comparisons (n = 579 760). The baseline mean age was 33.1 years (range 18-46 years). Results are presented as hazard ratios (HRs) with corresponding CIs.

MAIN RESULTS AND THE ROLE OF CHANCE

During follow-up (median 9.69 years among ART-treated and 9.28 years among untreated), 5861 women were diagnosed with breast cancer, 695 among ART-treated and 5166 among untreated women (1.1% versus 0.9%, P < 0.0001). Using Cox regression analyses adjusted for nulliparity, educational level, partnership status, year, maternal breast cancer and age, the risk of breast cancer was slightly increased among women treated with ART (HR 1.14, 95% CI 1.12-1.16). All causes of infertility were slightly associated with breast cancer risk after ART treatment. The risk of breast cancer increased with higher age at ART treatment initiation and was highest among women initiating treatment at age 40+ years (HR 1.37, 95% CI 1.29-1.45). When comparing women with a first birth at age 40+ years with or without ART treatment, the increased risk among women treated with ART persisted (HR 1.51, 95% CI 1.09-2.08).

LIMITATIONS, REASONS FOR CAUTION

Although this study is based on a large, national cohort of women, more research with sufficient power and confounder adjustment is needed, particularly in cohorts with a broad age representation.

WIDER IMPLICATIONS OF THE FINDINGS

An increased risk of breast cancer associated with a higher age at ART treatment initiation has been shown. Ovarian stimulation may increase the risk of breast cancer among women initiating ART treatment when aged 40+ years. Age-related vulnerability to hormone exposure or higher hormone doses during ART treatment may explain the increased risk.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by a PhD grant to D.V. from the Faculty of Health and Medical Sciences, University of Copenhagen, Denmark. Funding for establishing the DANAC II cohort was received from the Ebba Rosa Hansen Foundation. The authors report no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Subjectively perceived healthcare provision during the first wave of the COVID-19 pandemic

Background

An OECD benchmark (2020) shows that Germany has, in effect, an above-average healthcare infrastructure to face COVID-19. Nevertheless, at the beginning of the pandemic, there were restrictions and uncertainties in the use of health-related services. The following analysis examines the subjective perception of respondents with their healthcare provision whether there were sociodemographic differences.

Methods

Data from an online cross-sectional survey conducted between 29 April and 8 May 2020 were used (N = 1,570; 18-74 years). Bivariate test methods were used for analysis, stratified by age group, subjective social status (SSS) and chronic illness. The subjective perception was assessed via subjects' subjectively perceived worries, fears and difficulties of not receiving an adequate healthcare provision during the COVID-19 pandemic. Thus, an index was constructed with a range of values from 3 to 12 (Cronbach's α = 0.886). A higher index implies a poorer perception of the healthcare provision.

Results

Compared to the groups 50-59-year-olds and 60 years and older the 18-29-year-olds (MRank 431.1) had a significantly (p < 0.05) poorer perception of their healthcare provision during COVID-19. In addition, probands with low SSS were found to have a significantly (p < 0.05) worse perception (MRank 423.0) than subjects with medium SSS (MRank 374.1). Chronically ill subjects suffered significantly poorer perception (MRank 406.1; p < 0.05) compared to healthy subjects (MRank 366.0).

Conclusions

Vulnerable groups with poorer perceptions of their health care provision during COVID-19 can be identified. More investigation is needed to identify subjective or COVID-19 related predictors that cause this subjective perception.

Reference

OECD (2020). Beyond Containment: Health systems responses to COVID-19 in the OECD.

Available: https://read.oecd-ilibrary.org/view/?ref=119_119689-ud5comtf84&title=Beyond_Containment:Health_systems_responses_to_COVID-19_in_the_OECD (Accessed: 14.04.2021)

Key messages

It was found that respondents perceived their subjective healthcare provision during COVID-19 differently, according to sociodemographic stratification.

Especially younger, chronically ill, and socioeconomically deprived respondents experienced a poorer perception of their healthcare provision during the first wave of the COVID-19 pandemic.

Web-based planning tool for obesity prevention in childhood and youth – first trial period

Background

The systematic and theory-based development of interventions is complex and requires time and personnel resources. WEPI is a web-based planning tool for municipalities and schools, that follows the evidence-based intervention mapping approach (IMA) but also supports the planning process of obesity prevention user oriented. The project is supported by the Federal Ministry of Health, Germany.

Methods

Data of a systematic literature review (SLR), expert interviews and focus group discussions served as the foundation for the first version of WEPI. Two further SLR were conducted in the databases Pubmed, LIVIVO and Cochrane on evidence-based determinants of obesity development and on proven obesity intervention methods, to meet the requirements of the IMA. In October 2020 the second version of WEPI was tested with selected municipalities and schools. The prototype as a third version was tested by three municipalities and two schools in February 2021. Feedback was collected through questionnaires and interviews.

Results

In a total of 806 hits of the first SLR, determinants for the development of obesity were identified in 8 guidelines and 37 reviews. They were adopted in form of 15 problem areas which support the WEPI user to conduct an evidence-based problem analysis. Result of the second SLR are 25 obesity prevention interventions which were developed using the IMA. Based on this, 192 evaluated methods were identified and integrated as good practice examples into WEPI. In the first trial the expert feedback revealed aspects of content and user-friendliness as well as technical aspects that should be optimized. The feedback of the municipalities and schools underlines, that scientific findings need to be translated into practical logic.

Conclusions

WEPI provides a comprehensive roadmap to the planning process, guiding the user step by step. Acceptance and usability of the planning tool will be evaluated with municipalities and schools from April to November 2021.

Key messages

WEPI enables user oriented, structured and evidence-based planning of prevention interventions. Requirements resulting from practice were considered in the development of the planning tool.

MGMT promoter methylation testing to predict overall survival in people with glioblastoma treated with temozolomide: a comprehensive meta-analysis based on a Cochrane Systematic Review

BACKGROUND

The DNA repair protein O6-methylguanine-DNA methyltransferase (MGMT) causes resistance of tumor cells to alkylating agents. It is a predictive biomarker in high-grade gliomas treated with temozolomide, however, there is no consensus on which test method, methylation sites, and cutoff values to use.

METHODS

We performed a Cochrane Review to examine studies using different techniques to measure MGMT and predict survival in glioblastoma patients treated with temozolomide. Eligible longitudinal studies included (i) adults with glioblastoma treated with temozolomide with or without radiotherapy, or surgery; (ii) where MGMT status was determined in tumor tissue, and assessed by 1 or more technique; and (iii) where overall survival was an outcome parameter, with sufficient information to estimate hazard ratios (HRs). Two or more methods were compared in 32 independent cohorts with 3474 patients.

RESULTS

Methylation-specific PCR (MSP) and pyrosequencing (PSQ) techniques were more prognostic than immunohistochemistry for MGMT protein, and PSQ is a slightly better predictor than MSP.

CONCLUSIONS

We cannot draw strong conclusions about use of frozen tissue vs formalin-fixed paraffin-embedded in MSP and PSQ. Also, our meta-analysis does not provide strong evidence about the best CpG sites or threshold. MSP has been studied mainly for CpG sites 76-80 and 84-87 and PSQ at CpG sites ranging from 72 to 95. A cutoff threshold of 9% for CpG sites 74-78 performed better than higher thresholds of 28% or 29% in 2 of the 3 good-quality studies. About 190 studies were identified presenting HRs from survival analysis in patients in which MGMT methylation was measured by 1 technique only.

Macklon K, Schmidt L, Forman JL, Pinborg A. P–734 Parenthood among men diagnosed with cancer in childhood and early adulthood – trends over time in a Danish national cohort

Study question

Is the rate of fatherhood among men diagnosed with cancer in childhood and early adulthood different from men without cancer – have differences changed over time?

Summary answer

Men diagnosed with cancer had significantly reduced rates of fatherhood compared with undiagnosed men. Rates of fatherhood among the cancer survivors increased markedly over time.

What is known already

The number of children and young adolescents who survive cancer has steadily increased over the past decades, with a current 5-year survival rate of approximately 80%. Consequently, life circumstances after cancer have gained increasing importance, including the desire among survivors to have children and a family. MAR technologies to aid reproduction among cancer survivors have been developed, and fertility preservation is increasingly a topic being discussed before undergoing cancer treatment. But the potential for fertility preservation differs depending on age at diagnosis and type of cancer. Earlier studies have shown decreased fertility rates among survivors of childhood and adolescent cancer.

Study design, size, duration

This study is a national, register-based cohort study. Men diagnosed with cancer in childhood and early adulthood (&lt;30 years of age) were registered in the Danish Cancer Register in 1978–2016 (n = 15,600). At time of diagnosis, each cancer-diagnosed man was randomly age-matched with 150 undiagnosed men from the background population within the same birth year. The men were followed in medical registers and socio-demographic population registers until death, migration or end of study December 31st, 2017.

Participants/materials, setting, methods

Fatherhood among the boys and young men diagnosed with cancer was compared with the age-matched comparison group in all statistical analyses. Cancer diagnoses were categorized as central nervous system (CNS), haematological cancers or solid cancers. Also, analyses were stratified by age at diagnosis (0–9, 10–19, 20–29 years) and year of diagnosis (1978–89, 1990–99, 2000–16). Death was incorporated as a competing risk in all analyses.

Main results and the role of chance

The study population consisted of 15,600 boys and young men diagnosed with cancer between 1978 and 2016 and 1,386,493 men in the age-matched comparison group. Men surviving CNS cancer had the lowest hazard ratio of fatherhood compared with the age-matched comparison group (HR = 0.64, 95% CI 0.57–0.73), followed by survivors of haematological cancers (HR = 0.90, 95% CI 0.82–0.98) while the highest chance of fatherhood was slightly increased among survivors of solid cancers (HR = 1.13, 95% CI 1.10–1.16). The hazard ratio of becoming a father increased over time. From the first decade to the last decade 30 years later, the hazard ratio of becoming a father increased for solid tumours (HR 0.76, 95% CI 0.72–0.80 to HR 1.07, 95% CI 0.96–1.19), haematological tumours (HR 0.60, 95% CI 0.51–0.71 to HR 0.97, 95% CI 0.76–1.23) and CNS tumours (HR 0.47, 95% CI 0.39–0.58 to HR 1.04, 95% CI 0.56–1.93) compared to the age-matched comparison group. Also, men diagnosed with cancer when aged 20–29 years more likely became fathers over time (HR 0.79, 95% CI 0.74–0.84 to HR 1.09, 95% CI 0.98–1.22).

Limitations, reasons for caution

The study was based on register data, and information was not available about the men’s fertility potential, whether they had a desire to have children and whether it was possible for them to find a partner. Also, information about fertility preservation, e. g. sperm freezing, could have provided additional insights.

Wider implications of the findings: Information and education of male patients diagnosed with cancer about fertility preservation options, and chances to create their own family is crucial. Reassuringly, time trends showed more men with a previous cancer diagnosis becoming fathers in recent years than earlier, reflecting that survival and fertility preservation have improved over time.

Trial registration number

N/A

O-188 Participation in a video-based fertility awareness program advances the desire to have children sooner

Study question

Participating in a fertility awareness program accelerates the intention to have children 6 to 12 months after video- fertility awareness?

Summary answer

In combination with positive childbearing motivation, those in the video condition anticipated their intentions to have children at 6-12 months follow-up

What is known already

Fertility awareness education and initiatives have been focused on increasing fertility awareness and knowledge. However, the role of fertility awareness on reproductive decisions is less explored in literature. There are few studies showing that participating in fertility awareness education is related to higher intentions to have children or decreased time until trying to conceive regarding beforehand planned. Since intentions seem to be a good predictor of behaviour, we were interested in exploring the variables which might predict higher intentions to have children after participating in a fertility awareness education study based on a video intervention

Study design, size, duration

This study is part of a randomised controlled trial initiated in October 2016. Participants were randomly allocated into the intervention (IG) and control group (CG) at baseline (TO). The follow-up was evaluated 6 to 12 months later. IG participants were exposed to a 5-min video delivering information on age-related fertility decline, infertility risk factors, and pregnancy chances after having filled-in the T0 questionnaire: Participants in CG received no stimulus.

Participants/materials, setting, methods

Three hundred sixty-five individuals (65% women) were recruited through social media, gynaecology clinics, and religious pre-marital courses. From those, 128 responded to follow-up (between 6 and 12 months). Childbearing Motivation Scale (positive and negative) and a question about childbearing timing intentions were used. Regression analysis was conducted to explore the role of video intervention and childbearing motivation on childbearing timing intention.

Main results and the role of chance

Participants were, on average, 29.5 years old (SD = 5.13). From baseline to 6-12 months later, participants significantly anticipated their desire to have children (p&lt;.005). Correlations showed that childbearing timing intention was positively and significantly associated with the following subscales of the positive motivations: personal fulfilment, continuity, and couple relationship; negative motivations were not associated with the childbearing timing intention. The regression analysis revealed that only the childbearing motivation regarding couple relationship (having a child would strengthening partnership ties, fulfilling partner’s project, growing as a couple, fulfilling a shared project) and the visualization of the educational video significantly contributed to predicting at follow-up the increased desire to have children sooner at follow-up.

Limitations, reasons for caution

Other factors, not considered, might contribute to the prediction of childbearing motivation timing. Although we had randomly allocated people to CG and IG, the high attrition rate may limit the generalization of our results.

Wider implications of the findings

This study seems to indicate that watching an educational video about fertility awareness might contribute to a significant change in childbearing timing. In addition, the importance of the couple relationship is highlighted. These findings reinforce the importance to assist people with informed reproductive decisions in social and healthcare settings. 

Trial registration number

NCT02813993

P-472 Single mothers by choice - experiences of single women seeking treatment at a public fertility clinic in Denmark: A pilot study

Study question

Are single women in fertility treatment stigmatised and what do they experience?

Summary answer

The women did not feel stigmatised. They experienced self-blame and negative thoughts about themselves, despite experiencing empowerment and receiving positive reactions from families and friends.

What is known already

Since 2007, medical doctors in Denmark have been permitted to offer medically assisted reproduction (MAR) also to single women. Denmark is a welfare state with a public health care sector providing MAR free of charge, 240 days of paid parental leave, and public full-time day-care. There has been an increase in the number of single women deciding to have children through the use of MAR. These women are referred to as ‘single mothers by choice’ (SMC), and they have been criticised for being selfish when raising a child without a father. Previous studies have shown how SMC can feel stigmatised. 

Study design, size, duration

Semi-structured qualitative interviews at a public fertility clinic in Copenhagen, Denmark. Data collection took place between September and October 2020.

Participants/materials, setting, methods

The participants were single and childless women (N = 6) undergoing MAR at the Fertility Clinic, Rigshospitalet in Copenhagen, Denmark. Five women received IVF and one received IUI. The women were between 30 and 40 years old and were all residents in the Capital Region of Denmark. The interviews were audiotaped, anonymised, and transcribed in full. Data were analysed using qualitative content analysis.

Main results and the role of chance

Single women did not differ from cohabiting women seeking MAR in relation to their experiences and attitudes towards motherhood. Four main themes were identified; (1) Experiences of single women seeking fertility treatment, (2) Emotions associated with becoming a single mother by choice, (3) The decision of becoming a single mother by choice, and (4) Family formation – a social interaction. The women would have preferred to have a child in a relationship with a partner and the shattered dream about the nuclear family has caused a wide range of experiences and emotions. The women did not feel stigmatised but they all had an awareness of the prejudices other people might have towards single mothers by choice. Hence, they were ready to defend their choice if necessary. On the other hand, they had received positive reactions and the process of becoming a single mother by choice was influenced by their social relations with family and friends. Despite their dream of the nuclear family the women choose to become SMC because motherhood was of such importance and they feared they would otherwise become too old to have children – the biological clock was ticking. 

Limitations, reasons for caution

The participants were recruited from a public fertility clinic in the Capital Region of Denmark and may not be representative of all single women seeking MAR. Results might not be transferable to other countries with a different cultural context regarding the societal acceptance of different ways to establish a family. 

Wider implications of the findings

This study contributes to the understanding of the experiences of single women seeking fertility treatment in a welfare state where there are no differences in the possibilities for different social classes to seek MAR in the public health care sector. 

Trial registration number

N/A

P–493 Couples joint narratives of coping with and making sense of recurrent pregnancy loss: a dyadic interview study

Study question

What are couples’ joint narratives of coping with, and making sense of recurrent pregnancy loss?

Summary answer

Couples can become stuck in patterns of communication and coping roles that may be dissatisfying and not reflect the complexity of their experience of RPL.

What is known already

Fertility problems such as recurrent pregnancy loss (RPL) are unique health issues because they are a couple problem, in that they involve a blocked parenthood goal for both members of the couple regardless of the cause or source of the fertility issue.

Previous research has focused on the psychosocial impact on the individual or examined gender differences in men and women’s response to RPL. Research suggests that couples’ relationships are impacted, but few examine this issue in interviews with couples as participants. We need appropriate study designs to examine and understand the couple’s experience and process on a dyadic level.

Study design, size, duration

This was a qualitative study using dyadic interviews and analysis. This method facilitates a co-construction of meaning and joint narrative between couples through sharing and comparing their experience in a conjoint dyadic interview.

Thirteen couples who were referred to the RPL program, in Rigshospitalet, Copenhagen, Denmark were interviewed over a two-month period in 2017–2018. Interviews were held at Rigshospitalet and ranged between 81 and 109 minutes (average 91 minutes). Participants/materials, setting, methods: Inclusion criteria included: heterosexual couples with at least three pregnancy losses (PL) under 12 weeks gestation with no children/one child and willing to be interviewed in English. Thirty invitations were sent to couples who met the inclusion criteria and 15 couples contacted the interviewer to schedule an interview. Semi-structured dyadic interviews were conducted in person with 13 couples. Data was analyzed using dyadic analysis with a focus on common themes in co-constructed meaning across couples.

Main results and the role of chance

On average, participants had been in their relationship for 8.4 years, experienced three PLs (range three–six), with most recent PL occurring 4.3 months before the interview.

Couples described becoming stuck in patterns of communication and in rigid roles of coping and relating (e.g., the optimist, the emotional one) that could be dissatisfying and not meet their needs and not reflect the nuances and complexity of their experience of RPL. Common roles included the “optimist” versus the “pessimist”, the “talker” versus the “listener” and the “emotional” versus the “rational / problem solver”. While these roles were rooted in some truth of their experience, the rigidity of these roles did not create space and flexibility for the full spectrum of their reactions and experience. For example, a woman said, “I hope for him to be the pessimist so I get to be the optimist sometimes” and several men shared the depth of their grief for the first time.

The interviews were a way to highlight and create a new dynamic by allowing couples to respond to and correct their partner’s assumptions about their experience or role (e.g., “that’s not how I feel all the time”) and try new ways of communicating.

Limitations, reasons for caution

The findings cannot be generalized to all couples who have experienced RPL given the study design. Whilst dyadic interviews allow for a fuller, more nuanced narrative account, couples may omit some of their experience in the interview due to social desirability.

Wider implications of the findings: This study provides a better understanding of the complexity of communication patterns and roles in couples with RPL that can improve provision of support and counselling.

Dyadic interviews can provide opportunities for couples to communicate differently and break out of dissatisfying patterns while creating common ground and generating shared meaning.

Trial registration number

N/A

P–472 Single mothers by choice - experiences of single women seeking treatment at a public fertility clinic in Denmark: A pilot study

Study question

Are single women in fertility treatment stigmatised and what do they experience?

Summary answer

The women did not feel stigmatised. They experienced self-blame and negative thoughts about themselves, despite experiencing empowerment and receiving positive reactions from families and friends.

What is known already

Since 2007, medical doctors in Denmark have been permitted to offer medically assisted reproduction (MAR) also to single women. Denmark is a welfare state with a public health care sector providing MAR free of charge, 240 days of paid parental leave, and public full-time day-care. There has been an increase in the number of single women deciding to have children through the use of MAR. These women are referred to as ‘single mothers by choice’ (SMC), and they have been criticised for being selfish when raising a child without a father. Previous studies have shown how SMC can feel stigmatised. Study design, size, duration: Semi-structured qualitative interviews at a public fertility clinic in Copenhagen, Denmark. Data collection took place between September and October 2020.

Participants/materials, setting, methods

The participants were single and childless women (N = 6) undergoing MAR at the Fertility Clinic, Rigshospitalet in Copenhagen, Denmark. Five women received IVF and one received IUI. The women were between 30 and 40 years old and were all residents in the Capital Region of Denmark. The interviews were audiotaped, anonymised, and transcribed in full. Data were analysed using qualitative content analysis.

Main results and the role of chance

Single women did not differ from cohabiting women seeking MAR in relation to their experiences and attitudes towards motherhood. Four main themes were identified; (1) Experiences of single women seeking fertility treatment, (2) Emotions associated with becoming a single mother by choice, (3) The decision of becoming a single mother by choice, and (4) Family formation – a social interaction. The women would have preferred to have a child in a relationship with a partner and the shattered dream about the nuclear family has caused a wide range of experiences and emotions. The women did not feel stigmatised but they all had an awareness of the prejudices other people might have towards single mothers by choice. Hence, they were ready to defend their choice if necessary. On the other hand, they had received positive reactions and the process of becoming a single mother by choice was influenced by their social relations with family and friends. Despite their dream of the nuclear family the women choose to become SMC because motherhood was of such importance and they feared they would otherwise become too old to have children – the biological clock was ticking.

Limitations, reasons for caution

The participants were recruited from a public fertility clinic in the Capital Region of Denmark and may not be representative of all single women seeking MAR. Results might not be transferable to other countries with a different cultural context regarding the societal acceptance of different ways to establish a family.

Wider implications of the findings: This study contributes to the understanding of the experiences of single women seeking fertility treatment in a welfare state where there are no differences in the possibilities for different social classes to seek MAR in the public health care sector.

Trial registration number

N/A

Freiesleben NL, Husth M, Klajnbard A, Knudsen UB, Løssl K, Schmidt L, Pinborg A. P–484 Progesterone supplementation in modified natural frozen embryo transfer (mNC-FET) does not cause mental health adverse effects - A sub-study of a multicenter RCT

Study question

Do women undergoing mNC-FET with progesterone supplementation experience mental health adverse effects at a greater rate compared to a control group.

Summary answer

Progesterone supplementation does not affect mental wellbeing in women undergoing mNC-FET.

What is known already

Women and men undergoing assisted reproductive treatment more likely to experience stress and other adverse psychological effects than the background population. Various factors such as parental age, cause of infertility and treatment method have been shown to affect patient well-being. Progesterone supplementation is known to cause various physical adverse effects, yet few studies have investigated the potential mental health adverse effects of progesterone supplementation in FET.

Study design, size, duration

This is a sub-study of an ongoing RCT investigating the effect of luteal phase progesterone supplementation in mNC-FET. The aim is to investigate possible mental health adverse effects of progesterone. From 2019–2021 a total of 164 women were included (n = 84 and n = 82 in the progesterone and control group, respectively). The health and wellbeing self-reporting survey was fulfilled after randomization on hCG trigger + 11 days.

Participants/materials, setting, methods

A validated, electronic questionnaire in Danish was used to measure mental wellbeing in women aged 18–41 years undergoing mNC-FET with and without use of progesterone supplementation in the luteal phase at seven Danish public hospitals. Women were randomized to either progesterone treatment or no progesterone by a computerized randomization algorithm with minimization for female age &gt; =37 years, previous oocyte retrievals and previous FET. Comparisons of survey responses were performed by chi-square tests.

Main results and the role of chance

The survey response rate was 68%. We observed no significant differences in any of the three items between the progesterone group and the control group. On the first item “to which degree have you felt sensitive due to treatment”, 56% and 52% responded “to a large degree” or “to some degree” sensitive in the progesterone vs. control group, while 25% and 34% vs. 19% and 13% responded “to a lesser extent” or “not at all” sensitive in progesterone vs. controls (P = 0.35).

On the second item, “to which degree have you felt aggressive due to treatment”, 10% and 9% responded “to a large degree” or “to some degree”, 29% and 22% answered “to a lesser degree” and 62% and 70% responded “not at all” in the progesterone vs control group (P = 0.57).

On the third item “to which degree have you cried unexpectedly due to treatment” 25% and 18% responded “to a large degree” or “to some degree” in the progesterone vs control group, 20% and 27% answered “to a lesser extent”, while 55% in both groups answered “not at all” (P = 0.44).

Limitations, reasons for caution

In a self-reported survey selection bias, due to a less than 100% response rate, and reporting bias cannot be excluded. However with the possibility to answer the survey online at leisure, the risk of reporting bias is minimized.

Wider implications of the findings: A large concern for clinicians working with ART is patient wellbeing. Our study suggests that luteal phase support does not cause extra emotional distress, though further research is needed.

Trial registration number

NCT03795220

How do young men want to receive information about fertility? Young men's attitudes towards a fertility campaign targeting men in Copenhagen, Denmark

STUDY QUESTION

What are young men’s attitudes towards the Danish fertility campaign ‘How’s your sperm?’ and how do they want to receive fertility information in the future?

SUMMARY ANSWER

The young men found that the campaign had limited impact because it was not relevant to their current life situation and they believed general fertility awareness should be a mandatory part of education, while more targeted information would be helpful through web-based venues when it was more relevant to their lives (e.g. when ready to have children).

WHAT IS KNOWN ALREADY

It is estimated that 16–26% of the Danish population who want children will experience infertility at some point in their lives. In Denmark, 25% of young healthy men have decreased sperm quality, and 20% of 50-year-old men are childless. Men play an important role in the fertility decision-making of couples, thus, it is important to target men and ensure that they have sufficient fertility knowledge. However, fertility awareness is limited among men and there have been few fertility awareness initiatives targeting men. In October 2018, the Municipality of Copenhagen launched the campaign ‘How’s your sperm?’ as a tool to increase fertility knowledge among men. To identify potential barriers for the effect of fertility campaigns targeting men, evaluations of such campaigns are needed.

STUDY DESIGN, SIZE, DURATION

This study was a cross-sectional, qualitative study of six focus groups including a total of 27 currently childless young men from the Capital Region of Copenhagen, Denmark. Data collection took place between April and October 2019.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The interviewed young men were currently childless and were all residents in the Capital Region of Copenhagen. They were between 23 and 32 years old with an average age of 26 years, and almost all were university students or had a university degree. The focus group discussions were audiotaped, anonymized and transcribed in full. Data were analyzed using qualitative content analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

Overall, the campaign had limited influence on the young men because they believed the campaign was not relevant to their current life situation. Furthermore, the young men were confused about the aim and message of the campaign, as they thought it encouraged them to have their sperm quality tested. The young men also criticized the campaign for making a link between sperm quality and masculinity. They recognized the importance of knowledge about reproductive health but they wanted access to accurate information about fertility and risk factors for infertility. According to the young men, future initiatives should prioritize clear communication of accurate, reliable and understandable fertility information in web-based venues. In addition, the young men suggested that general fertility information should be a mandatory part of the (sexual) education curriculum in primary and secondary schools.

LIMITATIONS, REASONS FOR CAUTIONS

Participants were young and highly educated; thus the findings cannot be generalized to all men of a similar age group or to men at older ages.

WIDER IMPLICATIONS OF THE FINDINGS

Different strategies that are relevant to the lifespan are needed to increase fertility awareness in the male population. The young men’s responses underscored that any fertility awareness strategy or campaign must convey respect for the individual’s autonomy. The findings highlight that how information is communicated and the quality or type of information that is disseminated are both important in acceptability by target users.

STUDY FUNDING/COMPETING INTEREST(S)

No funding was received for this study. No conflicts were declared for all authors.

TRIAL REGISTRATION NUMBER

N/A.

Parenthood among men diagnosed with cancer in childhood and early adulthood: trends over time in a Danish national cohort

STUDY QUESTION

Is the rate of fatherhood among men diagnosed with cancer in childhood and early adulthood different from men without cancer, and, if so, have the differences changed over time?

SUMMARY ANSWER

Men diagnosed with cancer have had significantly reduced rates of fatherhood compared with undiagnosed men; however, the rates of fatherhood among the cancer survivors have increased markedly over time.

WHAT IS KNOWN ALREADY

The number of children and young adolescents who survive cancer has steadily increased over recent decades, with a current 5-year survival rate of approximately 80%. Consequently, life circumstances after cancer have gained increasing importance, including the desire among survivors to have children and a family. ARTs to aid reproduction among cancer survivors have been developed, and fertility preservation is increasingly a topic being discussed before undergoing cancer treatment. But the potential for fertility preservation differs dependent on age at diagnosis and type of cancer. Earlier studies have shown a decreased fertility rate among survivors of child and adolescent cancer compared to those diagnosed in early adulthood.

STUDY DESIGN, SIZE, DURATION

This study is a national, register-based cohort study. Men diagnosed with cancer in childhood and early adulthood (<30 years of age) were registered in the Danish Cancer Register in 1978-2016 (n = 9353). According to the time of diagnosis, each cancer-diagnosed man was randomly matched with 150 undiagnosed men from the background population within the same birth year. The men were followed until having their first child, death, migration or the end of the study (31 December 2017) in medical registers and socio-demographic population registers.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Fatherhood among the boys and young men diagnosed with cancer were compared with the age-matched comparison group in all statistical analyses. Cancer diagnoses were categorised as central nervous system (CNS) cancers, haematological cancers or solid cancers. Analyses were stratified by age at diagnosis (0-9, 10-19, 20-29 years) and time of diagnosis (1978-1989, 1990-1999, 2000-2009, 2010-2016). Death was incorporated as a competing risk in all analyses.

MAIN RESULTS AND THE ROLE OF CHANCE

The study population consisted of 9353 boys and young men diagnosed with cancer between 1978 and 2016 and 1 386 493 men in the age-matched comparison group. Those surviving CNS cancer as young men had the lowest hazard ratio (HR) of fatherhood compared with the age-matched comparison group (HR 0.67, 95% CI 0.57-0.79), followed by survivors of haematological cancers (HR 0.90, 95% CI 0.81-1.01), while the highest chance of fatherhood was among survivors of solid cancers (HR 1.16, 95% CI 1.12-1.20) with a slightly increased HR compared with undiagnosed males. The HR of becoming a father increased over time. From the first decade to the last decade 30 years later, the HR of becoming a father increased for solid tumours (HR 0.78, 95% CI 0.73-0.83 to HR 1.08, 95% CI 0.95-1.22), haematological cancers (HR 0.64, 95% CI 0.53-0.79 to HR 0.97, 95% CI 0.73-1.30) and CNS cancers (HR 0.44, 95% CI 0.34-0.57 to HR 0.98, 95% CI 0.49-1.95) compared to the age-matched comparison group. Also, when compared with the age-matched comparison group, men diagnosed with cancer when aged 20-29 years were more likely became fathers over the time of the study (HR 0.80, 95% CI 0.74-0.86 to HR 1.08, 95% CI 0.96-1.22).

LIMITATIONS, REASONS FOR CAUTION

The study was based on register data, and information was not available about the men's fertility potential, whether they had a desire to have children and whether it was possible for them to find a partner. Information about fertility preservation, e.g. sperm freezing, could also have provided additional insights. Furthermore, information about diagnosis and ART treatment would have been beneficial.

WIDER IMPLICATIONS OF THE FINDINGS

Information and education of male patients diagnosed with cancer about fertility preservation options and their chances to create their own family is crucial. Reassuringly, time trends showed more men with a previous cancer diagnosis becoming fathers in recent years than in earlier years, reflecting that survival and fertility preservation have improved over time.

STUDY FUNDING/COMPETING INTEREST(S)

R.S. received a PhD grant from the Rosa Ebba Hansen Foundation and from the Health Foundation (J.nr. 15-B-0095). The funding for the establishment of the DANAC II Cohort was obtained from the Rosa Ebba Hansen Foundation. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Data extraction methods for systematic review (semi)automation: Update of a living systematic review

Background: The reliable and usable (semi)automation of data extraction can support the field of systematic review by reducing the workload required to gather information about the conduct and results of the included studies. This living systematic review examines published approaches for data extraction from reports of clinical studies. Methods: We systematically and continually search PubMed, ACL Anthology, arXiv, OpenAlex via EPPI-Reviewer, and the  dblp computer science bibliography. Full text screening and data extraction are conducted within an open-source living systematic review application created for the purpose of this review. This living review update includes publications up to December 2022 and OpenAlex content up to March 2023. Results: 76 publications are included in this review. Of these, 64 (84%) of the publications addressed extraction of data from abstracts, while 19 (25%) used full texts. A total of 71 (93%) publications developed classifiers for randomised controlled trials. Over 30 entities were extracted, with PICOs (population, intervention, comparator, outcome) being the most frequently extracted. Data are available from 25 (33%), and code from 30 (39%) publications. Six (8%) implemented publicly available tools Conclusions: This living systematic review presents an overview of (semi)automated data-extraction literature of interest to different types of literature review. We identified a broad evidence base of publications describing data extraction for interventional reviews and a small number of publications extracting epidemiological or diagnostic accuracy data. Between review updates, trends for sharing data and code increased strongly: in the base-review, data and code were available for 13 and 19% respectively, these numbers increased to 78 and 87% within the 23 new publications. Compared with the base-review, we observed another research trend, away from straightforward data extraction and towards additionally extracting relations between entities or automatic text summarisation. With this living review we aim to review the literature continually.

Data extraction methods for systematic review (semi)automation: A living systematic review

Background: The reliable and usable (semi)automation of data extraction can support the field of systematic review by reducing the workload required to gather information about the conduct and results of the included studies. This living systematic review examines published approaches for data extraction from reports of clinical studies. Methods: We systematically and continually search MEDLINE, Institute of Electrical and Electronics Engineers (IEEE), arXiv, and the dblp computer science bibliography databases. Full text screening and data extraction are conducted within an open-source living systematic review application created for the purpose of this review. This iteration of the living review includes publications up to a cut-off date of 22 April 2020. Results: In total, 53 publications are included in this version of our review. Of these, 41 (77%) of the publications addressed extraction of data from abstracts, while 14 (26%) used full texts. A total of 48 (90%) publications developed and evaluated classifiers that used randomised controlled trials as the main target texts. Over 30 entities were extracted, with PICOs (population, intervention, comparator, outcome) being the most frequently extracted. A description of their datasets was provided by 49 publications (94%), but only seven (13%) made the data publicly available. Code was made available by 10 (19%) publications, and five (9%) implemented publicly available tools. Conclusions: This living systematic review presents an overview of (semi)automated data-extraction literature of interest to different types of systematic review. We identified a broad evidence base of publications describing data extraction for interventional reviews and a small number of publications extracting epidemiological or diagnostic accuracy data. The lack of publicly available gold-standard data for evaluation, and lack of application thereof, makes it difficult to draw conclusions on which is the best-performing system for each data extraction target. With this living review we aim to review the literature continually.

EU FP7 research funding for an orphan drug (Orfadin®) and vaccine (Hep C) development: a success and a failure?

BACKGROUND

We considered the extent of the contribution of publicly funded research to the late-stage clinical development of pharmaceuticals and medicinal products, based on the European Commission (EC) FP7 research funding programme. Using two EC FP7-HEALTH case study examples-representing two types of outcomes-we then estimated wider public and charitable research funding contributions.

METHODS

Using the publicly available database of FP7-HEALTH funded projects, we identified awards relating to late-stage clinical development according to the systematic application of inclusion and exclusion criteria, classified them according to product type and clinical indication, and calculated total EC funding amounts. We then identified two case studies representing extreme outcomes: failure to proceed with the product (hepatitis C vaccine) and successful market authorisation (Orfadin® for alkaptonuria). Total public and philanthropic research funding contributions to these products were then estimated using publicly available information on funding.

RESULTS

12.3% (120/977) of all EC FP7-HEALTH awards related to the funding of late-stage clinical research, totalling € 686,871,399. Pharmaceutical products and vaccines together accounted for 84% of these late-stage clinical development research awards and 70% of its funding. The hepatitis C vaccine received total European Community (FP7 and its predecessor, EC Framework VI) funding of €13,183,813; total public and charitable research funding for this product development was estimated at € 77,060,102. The industry sponsor does not consider further development of this product viable; this now represents public risk investment. FP7 funding for the late-stage development of Orfadin® for alkaptonuria was so important that the trials it funded formed the basis for market authorisation, but it is not clear whether the price of the treatment (over €20,000 per patient per year) adequately reflects the substantial public funding contribution.

CONCLUSIONS

Public and charitable research funding plays an essential role, not just in early stage basic research, but also in the late-stage clinical development of products prior to market authorisation. In addition, it provides risk capital for failed products. Within this context, we consider further discussions about a public return on investment and its reflection in pricing policies and decisions justified.

Prognostic value of test(s) for O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation for predicting overall survival in people with glioblastoma treated with temozolomide

BACKGROUND

Glioblastoma is an aggressive form of brain cancer. Approximately five in 100 people with glioblastoma survive for five years past diagnosis. Glioblastomas that have a particular modification to their DNA (called methylation) in a particular region (the O6-methylguanine-DNA methyltransferase (MGMT) promoter) respond better to treatment with chemotherapy using a drug called temozolomide.

OBJECTIVES

To determine which method for assessing MGMT methylation status best predicts overall survival in people diagnosed with glioblastoma who are treated with temozolomide.

SEARCH METHODS

We searched MEDLINE, Embase, BIOSIS, Web of Science Conference Proceedings Citation Index to December 2018, and examined reference lists. For economic evaluation studies, we additionally searched NHS Economic Evaluation Database (EED) up to December 2014.

SELECTION CRITERIA

Eligible studies were longitudinal (cohort) studies of adults with diagnosed glioblastoma treated with temozolomide with/without radiotherapy/surgery. Studies had to have related MGMT status in tumour tissue (assessed by one or more method) with overall survival and presented results as hazard ratios or with sufficient information (e.g. Kaplan-Meier curves) for us to estimate hazard ratios. We focused mainly on studies comparing two or more methods, and listed brief details of articles that examined a single method of measuring MGMT promoter methylation. We also sought economic evaluations conducted alongside trials, modelling studies and cost analysis.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook all steps of the identification and data extraction process for multiple-method studies. We assessed risk of bias and applicability using our own modified and extended version of the QUality In Prognosis Studies (QUIPS) tool. We compared different techniques, exact promoter regions (5'-cytosine-phosphate-guanine-3' (CpG) sites) and thresholds for interpretation within studies by examining hazard ratios. We performed meta-analyses for comparisons of the three most commonly examined methods (immunohistochemistry (IHC), methylation-specific polymerase chain reaction (MSP) and pyrosequencing (PSQ)), with ratios of hazard ratios (RHR), using an imputed value of the correlation between results based on the same individuals.

MAIN RESULTS

We included 32 independent cohorts involving 3474 people that compared two or more methods. We found evidence that MSP (CpG sites 76 to 80 and 84 to 87) is more prognostic than IHC for MGMT protein at varying thresholds (RHR 1.31, 95% confidence interval (CI) 1.01 to 1.71). We also found evidence that PSQ is more prognostic than IHC for MGMT protein at various thresholds (RHR 1.36, 95% CI 1.01 to 1.84). The data suggest that PSQ (mainly at CpG sites 74 to 78, using various thresholds) is slightly more prognostic than MSP at sites 76 to 80 and 84 to 87 (RHR 1.14, 95% CI 0.87 to 1.48). Many variants of PSQ have been compared, although we did not see any strong and consistent messages from the results. Targeting multiple CpG sites is likely to be more prognostic than targeting just one. In addition, we identified and summarised 190 articles describing a single method for measuring MGMT promoter methylation status.

AUTHORS' CONCLUSIONS

PSQ and MSP appear more prognostic for overall survival than IHC. Strong evidence is not available to draw conclusions with confidence about the best CpG sites or thresholds for quantitative methods. MSP has been studied mainly for CpG sites 76 to 80 and 84 to 87 and PSQ at CpG sites ranging from 72 to 95. A threshold of 9% for CpG sites 74 to 78 performed better than higher thresholds of 28% or 29% in two of three good-quality studies making such comparisons.

The association between antidepressant use and assisted reproductive technology (ART) treatment in Danish women: A national registry-based cohort study

OBJECTIVE

To investigate (1) if antidepressant use among women in assisted reproductive technology (ART) treatment and among women without ART treatment influences cumulative live birth rates (CLBR) and number of initiated treatment cycles per woman, (2) whether women undergoing ART treatment are at higher risk of initiating use of antidepressants compared to women not having undergone ART, (3) if mothers after ART treatment have higher risk for postpartum use of antidepressants after ART treatment compared to mothers not having used ART treatment.

STUDY DESIGN

A Danish nation-wide register-based cohort study including all women in ART treatment between 1995 through 2009 and an age-matched comparison group of women not having initiated ART treatment. In both groups, women had no previous children before study entry. The women were followed from time of initiating first ART treatment until time of permanent emigration (> 6 months), date of death, or end of follow-up by 31st of December 2009. Chi-square test was used to assess whether observed differences in CLBR between groups were significant. Adjusted incidence rates (IR) and incidence rate ratio (IRR) with 95 % confidence interval (CI) were calculated using Poisson regression analysis. The main outcome measures were: CLBR, number of initiated ART treatment cycles and IRR of initiating antidepressant use.

RESULTS

Women using antidepressants before, during or after ART treatment were significantly older, had a lower CLBR and a lower mean number of initiated ART treatment cycles compared to women in ART treatment with no use of antidepressants. No significant difference was found in the incidence of initiating antidepressant use between women in ART treatment and the comparison group. However, when comparing only women with a live birth, significantly more women in ART treatment initiated antidepressant use in the postpartum period (adjusted incidence rate ratio (IRR) = 2.56 (95 % CI 1.98-3.30; p < 0.001)).

CONCLUSION

Generally, women undergoing ART treatment are not at higher risk of initiating use of antidepressants compared with an age-matched comparison group not treated with ART. However, women with antidepressant medication use prior to ART initiate fewer ART treatments and have lower CLBR. Even though it has not been possible to adjust for all relevant confounders and our follow-up period only runs until the end of 2009, we still believe the results of this study to be highly relevant. According to our study, clinicians should be aware that women conceiving after ART treatment might experience an increased level of psychological strain during the postpartum period compared to mothers who conceived without ART.

Risk and Protective Factors in the COVID-19 Pandemic: A Rapid Evidence Map

Background: Given the worldwide spread of the 2019 Novel Coronavirus (COVID-19), there is an urgent need to identify risk and protective factors and expose areas of insufficient understanding. Emerging tools, such as the Rapid Evidence Map (rEM), are being developed to systematically characterize large collections of scientific literature. We sought to generate an rEM of risk and protective factors to comprehensively inform areas that impact COVID-19 outcomes for different sub-populations in order to better protect the public. Methods: We developed a protocol that includes a study goal, study questions, a PECO statement, and a process for screening literature by combining semi-automated machine learning with the expertise of our review team. We applied this protocol to reports within the COVID-19 Open Research Dataset (CORD-19) that were published in early 2020. SWIFT-Active Screener was used to prioritize records according to pre-defined inclusion criteria. Relevant studies were categorized by risk and protective status; susceptibility category (Behavioral, Physiological, Demographic, and Environmental); and affected sub-populations. Using tagged studies, we created an rEM for COVID-19 susceptibility that reveals: (1) current lines of evidence; (2) knowledge gaps; and (3) areas that may benefit from systematic review. Results: We imported 4,330 titles and abstracts from CORD-19. After screening 3,521 of these to achieve 99% estimated recall, 217 relevant studies were identified. Most included studies concerned the impact of underlying comorbidities (Physiological); age and gender (Demographic); and social factors (Environmental) on COVID-19 outcomes. Among the relevant studies, older males with comorbidities were commonly reported to have the poorest outcomes. We noted a paucity of COVID-19 studies among children and susceptible sub-groups, including pregnant women, racial minorities, refugees/migrants, and healthcare workers, with few studies examining protective factors. Conclusion: Using rEM analysis, we synthesized the recent body of evidence related to COVID-19 risk and protective factors. The results provide a comprehensive tool for rapidly elucidating COVID-19 susceptibility patterns and identifying resource-rich/resource-poor areas of research that may benefit from future investigation as the pandemic evolves.

Women's perceptions of fertility assessment and counselling 6 years after attending a Fertility Assessment and Counselling clinic in Denmark

STUDY QUESTION

What are women's perceptions and experience of fertility assessment and counselling 6 years after attending a Fertility Assessment and Counselling (FAC) clinic in Denmark?

SUMMARY ANSWER

Women viewed the personalized fertility knowledge and advice they received as important aids to decision-making and they felt the benefits outweighed the risks of receiving personalized fertility information.

WHAT IS KNOWN ALREADY

Many young people wish to become parents in the future. However, research demonstrates there is a gap in women's and men's knowledge of fertility and suggests they may be making fertility decisions based on inaccurate information. Experts have called for the development of interventions to increase fertility awareness so that men and women can make informed fertility decisions and achieve their family-building goals. Since 2011, the FAC clinic in Copenhagen, Denmark has provided personalized fertility assessment and guidance based on clinical examination and evaluation of individual risk factors. Available qualitative research showed that attending the FAC clinic increased fertility awareness and knowledge and was experienced as a catalyst for change (e.g. starting to conceive, pursuing fertility treatment, ending a relationship) in women 1-year post-consultation.

STUDY DESIGN SIZE DURATION

The study was a 6-year follow-up qualitative study of 24 women who attended the FAC clinic between January and June 2012. All women were interviewed during a 2-month period from February to March 2018 at Rigshospitalet, their home or office, in Copenhagen, Denmark. Interviews were held in English and ranged between 60 and 94 min (mean 73 min).

PARTICIPANTS/MATERIALS SETTING METHODS

Invitations to participate in an interview-based follow-up study were sent to 141 women who attended the FAC clinic in 2012. In total, 95 women read the invitation, 35 confirmed interest in participating and 16 declined to participate. Twenty-five interviews were booked and 24 interviews held. Interviews followed a semi-structured format regarding reasons for attending the FAC clinic, if/how their needs were met, and perceptions of fertility assessment and counselling. Data were analysed using thematic analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

At the follow-up interview, women were on average 39.5 years old. Ten were currently single or dating and 14 were married/cohabiting. All were childless when they attended the FAC clinic. At the follow-up interview, 21 women were parents (14 women with one child; 6 with two children; 1 with three children) and the remaining three women intended to have children in the future. The most common reason for originally attending the FAC clinic was to determine how long they could delay childbearing. Most of the women now believed their needs for attending had been met. Those who were dissatisfied cited a desire for more exact ('concrete') information as to their remaining years of fertility, although acknowledged that this was likely not realistic. Women stated that they had felt reassured as to their fertility status after attending the FAC clinic whilst receiving the message that they could not delay childbearing 'too long'. Women viewed personalized fertility knowledge as an important aid to decision-making but cautioned about developing a false sense of security about their fertility and chance of conceiving in the future based on the results. Although women were generally satisfied with their experience, they wished for more time to discuss options and to receive additional guidance after their initial meeting at the FAC clinic.

LIMITATIONS REASONS FOR CAUTION

Participants were from a group of Danish women attending the FAC clinic and interviews were conducted in English, which means they are not representative of all reproductive-aged women. Nevertheless, the study group included a broad spectrum of women who achieved parenthood through different means (heterosexual/lesbian relationship, single parent with donor, co-parent) with various family sizes, and women who were currently childless.

WIDER IMPLICATIONS OF THE FINDINGS

Our study provides support for an individualized approach to fertility education, assessment and counselling provided at a time when the information is relevant to the individual and their current fertility decision-making. The findings suggest that although satisfied with their visit to the FAC clinic, the women wished for more information and guidance after this visit, suggesting that the current intervention may need to be expanded or new interventions developed to meet these additional needs.

STUDY FUNDING/COMPETING INTERESTS

E.K. was funded by an ESHRE Travel/Training grant by ReproUnion, co-financed by the European Union, Interreg V OKS. J.B. reports that the risk evaluation form used at the Fertility Assessment Clinic was inspired by the Fertility Status Awareness Tool FertiSTAT that was developed at Cardiff University for self-assessment of reproductive risk. J.B. also reports personal fees from Merck KGaA, Merck AB, Theramex, Ferring Pharmaceuticals A/S and a research grant from Merck Serono Ltd outside the submitted work. A.N.A. has received personal fees from both Merck Pharmaceuticals and Ferring and grants from Roche Diagnostics outside the submitted work. The other authors report no conflicts of interest.

The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: a living systematic review

Background: The COVID-19 pandemic has caused morbidity and mortality, as well as, widespread disruption to people's lives and livelihoods around the world. Given the health and economic threats posed by the pandemic to the global community, there are concerns that rates of suicide and suicidal behaviour may rise during and in its aftermath. Our living systematic review (LSR) focuses on suicide prevention in relation to COVID-19, with this iteration synthesising relevant evidence up to June 7 th 2020. Method:  Automated daily searches feed into a web-based database with screening and data extraction functionalities. Eligibility criteria include incidence/prevalence of suicidal behaviour, exposure-outcome relationships and effects of interventions in relation to the COVID-19 pandemic. Outcomes of interest are suicide, self-harm or attempted suicide and suicidal thoughts. No restrictions are placed on language or study type, except for single-person case reports. Results: Searches identified 2070 articles, 29 (28 studies) met our inclusion criteria, of which 14 articles were research letters or pre-prints awaiting peer review. All articles reported observational data: 12 cross-sectional; eight case series; five modelling; and three service utilisation studies. No studies reported on changes in rates of suicidal behaviour. Case series were largely drawn from news reporting in low/middle income countries and factors associated with suicide included fear of infection, social isolation and economic concerns.   Conclusions:  A marked improvement in the quality of design, methods, and reporting in future studies is needed. There is thus far no clear evidence of an increase in suicide, self-harm, suicidal behaviour, or suicidal thoughts associated with the pandemic. However, suicide data are challenging to collect in real time and economic effects are evolving. Our LSR will provide a regular synthesis of the most up-to-date research evidence to guide public health and clinical policy to mitigate the impact of COVID-19 on suicide. PROSPERO registration: CRD42020183326 01/05/2020.

The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: update of living systematic review

Background: The COVID-19 pandemic has caused considerable morbidity, mortality and disruption to people's lives around the world. There are concerns that rates of suicide and suicidal behaviour may rise during and in its aftermath. Our living systematic review synthesises findings from emerging literature on incidence and prevalence of suicidal behaviour as well as suicide prevention efforts in relation to COVID-19, with this iteration synthesising relevant evidence up to 19 th October 2020. Method:  Automated daily searches feed into a web-based database with screening and data extraction functionalities. Eligibility criteria include incidence/prevalence of suicidal behaviour, exposure-outcome relationships and effects of interventions in relation to the COVID-19 pandemic. Outcomes of interest are suicide, self-harm or attempted suicide and suicidal thoughts. No restrictions are placed on language or study type, except for single-person case reports. We exclude one-off cross-sectional studies without either pre-pandemic measures or comparisons of COVID-19 positive vs. unaffected individuals. Results: Searches identified 6,226 articles. Seventy-eight articles met our inclusion criteria. We identified a further 64 relevant cross-sectional studies that did not meet our revised inclusion criteria. Thirty-four articles were not peer-reviewed (e.g. research letters, pre-prints). All articles were based on observational studies. There was no consistent evidence of a rise in suicide but many studies noted adverse economic effects were evolving. There was evidence of a rise in community distress, fall in hospital presentation for suicidal behaviour and early evidence of an increased frequency of suicidal thoughts in those who had become infected with COVID-19. Conclusions:  Research evidence of the impact of COVID-19 on suicidal behaviour is accumulating rapidly. This living review provides a regular synthesis of the most up-to-date research evidence to guide public health and clinical policy to mitigate the impact of COVID-19 on suicide risk as the longer term impacts of the pandemic on suicide risk are researched.

Age-related natural fertility outcomes in women over 35 years: a systematic review and individual participant data meta-analysis

STUDY QUESTION

What is the rate of natural conception leading to ongoing pregnancy or livebirth over 6–12 months for infertile women of age ≥35 years?

SUMMARY ANSWER

Natural conception rates were still clinically relevant in women aged 35 years and above and were significantly higher in women with unexplained infertility compared to those with other diagnoses.

WHAT IS KNOWN ALREADY

In recent years, increasing numbers of women have attempted to conceive at a later age, resulting in a commensurate increase in the need for ART. However, there is a lack of data on natural fertility outcomes (i.e. no interventions) in women with increasing age.

STUDY DESIGN, SIZE, DURATION

A systematic review with individual participant data (IPD) meta-analysis was carried out. PubMed, MEDLINE, EMBASE, the Cochrane Library, clinicaltrials.gov were searched until 1 July 2018 including search terms ‘fertility service’, ‘waiting list’, ‘treatment-independent’ and ‘spontaneous conception’. Language restrictions were not imposed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Inclusion criteria were studies (at least partly) reporting on infertile couples with female partner of age ≥35 years who attended fertility services, underwent fertility workup (e.g. history, semen analysis, tubal status and ovulation status) and were exposed to natural conception (e.g. independent of treatment such as IVF, ovulation induction and tubal surgery). Studies that exclusively studied only one infertility diagnosis, without including other women presenting to infertility services for other causes of infertility, were excluded. For studies that met the inclusion criteria, study authors were contacted to provide IPD, after which fertility outcomes for women of age ≥35 years were retrieved. Time to pregnancy or livebirth and the effect of increasing age on fertility outcomes after adjustment for other prognostic factors were analysed. Quality of studies was graded with the Newcastle–Ottawa Scale (non-randomised controlled trials (RCTs)) or the Cochrane Risk of Bias tool (for RCTs).

MAIN RESULTS AND THE ROLE OF CHANCE

We included nine studies (seven cohort studies and two RCTs) (n = 4379 women of at least age 35 years), with the observed composite primary outcome of ongoing pregnancy or livebirth occurring in 429 women (9.8%) over a median follow-up of 5 months (25th to 75th percentile: 2.5–8.5 months). Studies were of moderate to high quality. The probability of natural conception significantly decreased with any diagnosis of infertility, when compared with unexplained infertility. We found non-linear effects of female age and duration of infertility on ongoing pregnancy and tabulated the predicted probabilities for unexplained infertile women aged 35–42 years with either primary or secondary infertility and with a duration of infertility from 1 to 6 years. For a 35-year-old woman with 2 years of primary unexplained infertility, the predicted probability of natural conception leading to ongoing pregnancy or livebirth was 0.15 (95% CI 0.11–0.19) after 6 months and 0.24 (95% CI 0.17–0.30) after 12 months. For a 42-year-old woman, this decreased to 0.08 (95% CI 0.04–0.11) after 6 months and 0.13 (95% CI 0.07–0.18) after 12 months.

LIMITATIONS, REASONS FOR CAUTION

In the studies selected, there were different study designs, recruitment strategies in different centres, protocols and countries and different methods of assessment of infertility. Data were limited for women above the age of 40 years.

WIDER IMPLICATIONS OF THE FINDINGS

Women attending fertility services should be encouraged to pursue natural conception while waiting for treatment to commence and after treatment if it is unsuccessful. Our results may aid in counselling women, and, in particular, for those with unexplained infertility.

STUDY FUNDING/COMPETING INTEREST(S)

S.J.C. received funding from the University of Adelaide Summer Research Scholarship. B.W.M. is supported by a NHMRC Investigator grant (GNT1176437), B.W.M. reports consultancy for ObsEva, Merck, Merck KGaA, iGenomix and Guerbet. B.W.M. reports research support by Merck and Guerbet.

PROSPERO REGISTRATION NUMBER

CRD42018096552.

Patients' attitudes and preferences towards a freeze-all strategy in ART treatment

STUDY QUESTION

What are the attitudes towards different aspects of a freeze-all strategy and elective frozen embryo transfer (eFET) in comparison with fresh embryo transfer in assisted reproductive technology treatment among female and male patients before and after their first ART treatment cycle in a public health care setting?

SUMMARY ANSWER

Despite concerns about the delay in embryo transfer associated with eFET, nearly 60% of the participants were in favor of eFET compared with fresh embryo transfer assuming that the clinical pregnancy rate was equivalent.

WHAT IS KNOWN ALREADY

Vitrification and blastocyst transfer have considerably improved success rates after FET with ongoing pregnancy rates in frozen cycles approaching those seen in fresh treatment cycles. Furthermore, the risk of ovarian hyperstimulation syndrome (OHSS) is essentially eliminated in FET cycles, and FET may be beneficial to the endometrial and fetal development because a hormonal environment mirroring the natural cycle is enabled. However, the freeze-all strategy is not yet implemented as standard care. One reason is the presumption of negative patient attitudes towards a freeze-all embryo strategy. So far, no data regarding patients' attitudes on a freeze-all strategy have been published.

STUDY DESIGN, SIZE, DURATION

This study was designed as a descriptive cross-sectional study including 165 fertility patients referred for their first ART treatment from December 2014 to June 2016.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All newly referred patients participating in a mandatory meeting before initiating ART treatment at the Fertility Clinic, Hvidovre Hospital, Copenhagen, Denmark were requested to fill in an online web-based questionnaire separately for men and women covering attitudes towards a freeze-all strategy, socio-demographic data and reproductive history. The patients were informed about both conventional fresh embryo transfer strategy and the freeze-all strategy prior to answering the questionnaire.

MAIN RESULTS AND THE ROLE OF CHANCE

The total response rate was 77.1% (n = 165), and for women and men respectively 85.8 versus 66.0%. The female respondents were significantly more likely to consider the postponement of embryo transfer difficult compared to the male population (78.6 versus 35.5%; P < 0.001) and they were significantly more willing to accept a risk in treatment on own health to achieve a pregnancy than were the male respondents on their partners health (82.5 versus 96.8%; P = 0.025). However, 59.2% of the women and 59.7% of the men agreed that they would choose eFET over fresh embryo transfer if the chance of pregnancy were the same. Most of the patients furthermore agreed that the health of the mother and their baby was of highest importance. In the adjusted analyses we found no significant predictive factors for preferences towards a freeze-all strategy apart from a negative attitude towards delay of transfer in case of previous unsuccessful ART attempts.

LIMITATIONS, REASONS FOR CAUTION

Selection bias cannot be excluded, as the total response rate was 77.1%. The hypothetical nature of the items may furthermore limit the validity of the results. In addition, the participants were from a single Fertility Clinic in the Capital Region of Denmark and may therefore not be representative for all fertility patients.

WIDER IMPLICATIONS OF THE FINDINGS

In a clinical setting with similar pregnancy rates for eFET and fresh embryo transfer, these results indicate that patients, when given access to information on advantages and disadvantages of both fresh embryo transfer and eFET, are less prone to opt for fresh embryo transfer. This may be ground breaking for a patient-centered paradigm shift in routine ART treatment with a wider implementation of a freeze-all and eFET-strategy eliminating the risk of OHSS.

STUDY FUNDING/COMPETING INTEREST(S)

The Danish Council for Independent Research and Merck Serono supported the study. The study is part of the Reprounion Collaborative study, co-financed by the European Union, Interreg V ÖKS. No competing interests exist.

Recurrent pregnancy loss: couples' perspectives on their need for treatment, support and follow up

STUDY QUESTION

What do couples referred to or attending a recurrent pregnancy loss (RPL) clinic believe they need in terms of treatment, support and follow up?

SUMMARY ANSWER

Men and women wish for more information, earlier access to treatment, support and follow up that is sensitive to their history of pregnancy loss (PL), includes both members of the couple, and acknowledges the psychological impact of RPL.

WHAT IS KNOWN ALREADY

Previous research has highlighted women's dissatisfaction with medical care provided post-PL and their desire for medical professionals to have increased awareness about PL and recognition of the psychological impact of PL. Less is known about the needs of the male partner, the needs of those experiencing RPL and whether the needs differ during different reproductive stages.

STUDY DESIGN, SIZE, DURATION

Over a 2-month period in 2017-2018, 13 couples who were referred to the national RPL program in Copenhagen, Denmark were qualitatively interviewed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Inclusion criteria were heterosexual couples with at least three consecutive PLs before 12 weeks' gestation with no children or one child prior to the PLs, not currently pregnant, and willing to be interviewed in English. Couples were interviewed together in a semi-structured format. Data were analyzed using thematic analysis. Invitations (n = 30) were sent to couples recently referred to the RPL program who indicated an interest in participating and 17 couples contacted the interviewer to schedule an interview. Due to cancellations, 15 interviews were held. Data from 13 interviews that met the study criteria were used for the current analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

The participants had experienced a median of three PLs (range 3-6). Both men and women described the cumulative effect of RPL with an increase in pressure and exhaustion by the third and subsequent losses. Inclusion of the male partner in consultations and treatment was seen as important. Men felt pressured to remain positive and support their partners despite their own feelings of loss. The findings showed that couples desired reliable and accurate information about RPL. They wished for recognition from the medical community that RPL has a significant psychological impact, and stressed that effective treatment should include both members of the couple, with attention to both physical and psychological aspects of the RPL and should be tailored to their current reproductive stage, in order to help them cope with the negative impact of RPL and the anxiety associated with conception and another pregnancy.

LIMITATIONS, REASONS FOR CAUTION

Participants were self-selected thus findings cannot be generalized to all couples with RPL.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first study addressing the needs of the female and male partners in couples suffering from RPL. The findings highlight a disconnect between couples' perceived needs and their experience of medical care after RPL. This may be partly due to a discrepancy in couples' and medical professionals' perceptions of the PLs. The findings highlight that medical professionals need to take a holistic and couple-focused approach in their treatment of RPL and include attention to the psychological impact and cumulative effect of the multiple PLs on the couple. The results underscore the need for informational resources and psychological support for couples experiencing RPL, tailored to their reproductive stage.

STUDY FUNDING/COMPETING INTEREST(S)

EK was funded by a Travel/Training Fellowship from ReproUnion, co-financed by the European Union, Interreg V ÖKS. No other competing interests were declared.

TRIAL REGISTRATION NUMBER

N/A.