The experience of infertility: a review of recent literature

Is perceived inability to procreate associated with life satisfaction? Evidence from a German panel study

Most studies of the psychosocial consequences of infertility have focused on those who seek medical treatment, leaving a research gap regarding the psychosocial consequences of perceived inability to procreate in the general population. Moreover, most studies are cross-sectional and the results are thus likely affected by omitted variable bias. Inspired by aspects of the Theory of Conjunctural Action, this study analysed 10 waves of data from the German Family Panel (pairfam) for women and men using fixed effects panel regression and including time-varying control variables suggested by theory and research. This study found that both women and men experienced lower life satisfaction in years when they perceived an inability to procreate. This association was not affected by the inclusion of relevant time-varying control variables. Furthermore, the association between perceived barriers to procreation and life satisfaction was found to differ depending on life circumstances and gender. Women with partners and men without partners had lower life satisfaction when they perceived an inability to procreate compared with when they did not. Women and men who intended to have a(nother) child had lower life satisfaction when they perceived an inability to procreate compared with when they did not. The association, however, was only significant for men. Somewhat surprisingly, women who perceived an inability to procreate also had lower life satisfaction when they were not intending to have a(nother) child. This study makes an important contribution to research on the psychosocial consequences of perceived infertility, and provides insights into why some people may pursue assisted reproductive technology for family creation.

Late fertility intentions increase over time in Austria, but chances to have a child at later ages remain low

Childbearing takes place at increasingly older ages, and fertility is continuing to decrease across female birth cohorts. This study investigated whether the proportion of women who unintentionally forwent childbearing increased over time, and linked this to the age profile of fertility intentions and realization among men and women. This study was based on the Austrian Micro-Censuses (1986-2016) and on the Austrian Generations and Gender Surveys (panel data 2008/09 and 2012/13). Across the birth cohorts 1950-1979, an increasing proportion of women wanted to have children after 40 years of age, but more women failed to meet their fertility intentions expressed at 34-36 years of age. At the individual level, from 30 years of age, more than one-third of women and men with a strong fertility intention were found to persist with this intention within four years even at less fertile ages. In addition, women and men with a strong fertility intention became less likely to have a child with age: <10% of women and approximately 20% of men who had expressed a certain and short-term intention to have a child at 39-41 years of age in 2008/09 had a child by 2012/13. In particular, childless women and men, and those with only one child, persisted in certain and short-term positive intentions from 30 years of age, but parity was not a significant factor in their realization. The sharp increase in 'unrealized fertility' over time draws attention to the importance that personal circumstances and context encountered at older ages may have for fertility, and augurs a continued increase in the use of assisted reproduction.

Recellularized rat testis scaffolds with embryoid bodies cells: a promising approach for tissue engineering

Tissue engineering is gaining use to investigate the application of its techniques for infertility treatment. The use of pluripotent embryonic cells for in vitro production of viable spermatozoa in testicular scaffolds is a promising strategy that could solve male infertility. Due to cell-extracellular matrix (ECM) interactions, here we aim to investigate the differentiation of embryoid bodies (EBs) in cultured into decellularized rat testis scaffolds. Decellularized testis (P = 0.019) with a low concentration of gDNA (30.58 mg/ng tissue) was obtained by sodium dodecyl sulfate perfusion. The structural proteins (collagens type I and III) and the adhesive glycoproteins of ECM (laminin and fibronectin) were preserved according to histological and scanning electron microscopy (SEM) analyses. Then, decellularized rat testis were cultured for 7 days with EB, and EB mixed with retinoic acid (RA) in non-adherent plates. By SEM, we observe that embryonic stem cells adhered in the decellularized testis ECM. By immunofluorescence, we verified the positive expression of HSD17B3, GDNF, ACRV-1, and TRIM-36, indicating their differentiation using RA in vitro, reinforcing the possibility of EB in male germ cell differentiation. Finally, recellularized testis ECM may be a promising tool for future new approaches for testicular cell differentiation applied to assisted reproduction techniques and infertility treatment.Abbreviations: ACRV-1: Acrosomal vesicle protein 1; ATB: Penicillin-streptomycin; DAPI: 4,6-Diamidino-2-phenylindole; EB: Embryoid bodies; ECM: Extracellular matrix; ESCs: Pluripotent embryonic stem cells; GAGs: Glycosaminoglycans; gDNA: Genomic DNA; GDNF: Glial cell line-derived neurotrophic factor; H&E: Hematoxylin and eosin; HSD17B3: 17-beta-Hydroxysteroid dehydrogenase type 3; PBS: Phosphate-buffered saline; PGCLCs: Primordial germ-cell-like cells; RA: Retinoic acid; SDS: Sodium dodecyl sulfate; SEM: Scanning electron microscopy; SSCs: Spermatogonial stem cells; TRIM-36: Tripartite Motif Containing 36.

The Infertility-Related Stress Scale: Validation of a Brazilian-Portuguese Version and Measurement Invariance Across Brazil and Italy

Infertility constitutes an essential source of stress in the individual and couple's life. The Infertility-Related Stress Scale (IRSS) is of clinical interest for exploring infertility-related stress affecting the intrapersonal and interpersonal domains of infertile individuals' lives. In the present study, the IRSS was translated into Brazilian-Portuguese, and its factor structure, reliability, and relations to sociodemographic and infertility-related characteristics and depression were examined. A sample of 553 Brazilian infertile individuals (54.2% female, mean aged 36 ± 6 years) completed the Brazilian-Portuguese IRSS (IRSS-BP), and a subsample of 222 participants also completed the BDI-II. A sample of 526 Italian infertile individuals (54.2% female, mean aged 38 ± 6 years) was used to test for the IRSS measurement invariance across Brazil and Italy. Results of exploratory structural equation modeling (ESEM) indicated that a bifactor solution best represented the structure underlying the IRSS-BP. Both the general and the two specific intrapersonal and interpersonal IRSS-BP factors showed satisfactory levels of composite reliability. The bifactor ESEM solution replicated well across countries. As evidence of relations to other variables, female gender, a longer duration of infertility, and higher depression were associated with higher scores in global and domain-specific infertility-related stress. The findings offer initial evidence of validity and reliability of the IRSS-BP, which could be used by fertility clinic staff to rapidly identify patients who need support to deal with the stressful impact of infertility in the intrapersonal and interpersonal life domains, as recommended by international guidelines for routine psychosocial care in infertility settings.

Posttraumatic Growth in Women With a Long-Standing Experience of Involuntary Childlessness in the Czech Republic

This qualitative research study aimed to examine aspects of posttraumatic growth (PTG) in women with a long-standing experience of involuntary childlessness. In-depth semi-structured interviews, lasting an average of 53 min, were conducted in the Czech Republic. Twenty-four women, averaging 38.8 years old with an average of 6.2 years of infertility experience, participated. They were asked how involuntary childlessness affected/changed their partnerships, sexual life, job, future plans, attitude to children/values/faith, and leisure time. Participants shared both positive and negative aspects of the infertility experience. Data were analyzed using thematic analysis. Five main themes of PTG were identified: strengthening of partnership, greater humility, deeper self-appreciation, reassessment of relationships, and changes in the philosophy of life. These findings could be useful to mental health providers to facilitate the PTG process in patients.

Infertility-related stress: A concept analysis

AIM

To develop a clear definition of infertility-related stress using Rodgers' method of concept analysis.

BACKGROUND

Infertility affects approximately 13% of women in the United States. Though poorly defined in the literature, previous studies suggest infertility-related stressors contribute to psychological distress.

DESIGN

Rodgers' method of concept analysis guided the review, including sample and setting, literature search, and data analysis.

DATA SOURCE

PubMed, CINAHL, and PsycINFO were searched for relevant literature.

REVIEW METHODS

Following abstract, title, and text screenings, 21 articles were included and reported using the PRISMA-S checklist. Texts were analyzed and results informed the proposed definition of infertility-related stress.

RESULTS

Antecedents included infertility, desire for children, and fear of the unknown. Attributes were identity crisis, social isolation and stigma, sexual stress, and financial strain. Consequences included treatment dropout and marital strain. Anxiety, depression, and decreased quality of life were identified as both attributes and consequences.

CONCLUSIONS

Synthesized results informed a proposed definition of infertility-related stress. Improved understanding of infertility-related stress allows for measurement development and facilitates recognition of patients in need of additional support, while potentially reducing the impact on the health and well-being of infertile women.

Fertility-Related Quality of Life in Men Undergoing Medically Assisted Reproduction During the Pandemic: Perfectionism and Thought Control Beliefs Moderate the Effects of the Type of Treatment

OBJECTIVE

After a diagnosis of infertility, an increasing number of couples turns to the Medically Assisted Reproduction (MAR) to achieve a pregnancy. A diagnosis of infertility has a negative impact on the individual's well-being and it can increase the risk of anxious-depressive symptoms, stress, and low self-esteem. Data associated with infertility-related Quality of Life (QoL) are lacking in men. Little is known about men's experience of infertility and its treatments during the pandemic. Among the variables potentially associated with infertility-related QoL, the role of obsessive beliefs is neglected, although preliminary studies considered perfectionistic traits.

METHOD

One hundred and fifty-one participants were included. Eighty men (mean age: 40.83 years) were attending a MAR pathway. Of these, 50 men (67.5%) were undergoing homologous MAR and 30 men (37.5%) were undergoing heterologous MAR. A control group consisting of 71 subjects (mean age: 36.69 years), paired by age, marital status, and number of children, was drawn from the general population. The Obsessive Beliefs Questionnaire-46, the Depression Anxiety Stress Scales-20, and the Fertility Quality of Life Questionnaire were administered.

RESULTS

High levels of anxiety, depression and stress were moderately associated with lower infertility-related Quality of Life. For men undergoing homologous MAR, perfectionism beliefs represented a vulnerability factor for a lower fertility-related QoL, while for men undergoing heterologous MAR, high thought control beliefs represented a risk factor for a lower fertility-related QoL.

CONCLUSIONS

A focus on the obsessive beliefs should be included in the psychological treatment of infertile men, specifically perfectionism in homologous MAR and control of thoughts in heterologous MAR. Therefore, psychological assessment and support interventions should be personalized according to the MAR pathway and be focused on men's cognitive features in order to improve their QoL during the MAR pathway.

KNOWLEDGE AND PERCEPTION OF INFERTILITY AMONG ADULT MALES IN IBADAN, NIGERIA

BACKGROUND

Infertility is a public health problem with significant social and psychological distress of the affected men due to the inability to achieve the desired social role of fatherhood. Men with infertility may experience lower life satisfaction, heightened distress and anxiety. This study assessed the knowledge, perception and factors influencing knowledge and perception of infertility among adult males in Ibadan, Nigeria.

METHODS

Cross-sectional descriptive survey was conducted among 388 adult males between April and November 2019 in the selected communities. Respondents were interviewed using a pretested structured questionnaire. Data was analysed with SPSS version 22. Descriptive and bivariate analyses were conducted. Level of significance was set at p≤5%.

RESULTS

The mean age of the respondents was 45.74±10.76 years. Majority were married 310(80%) and had tertiary education 234(60%). Less than half (48.7%) understood the correct meaning of infertility, 170(44%) agreed that witchcraft could cause infertility while 230(59%) disagreed that infertility could be prevented. Two hundred and sixty (67%) and 283 (73%) of the respondents had good knowledge and perception towards infertility respectively. Religion, education and income were statistically significant with knowledge of infertility (p<0.05). In addition, knowledge and perception of infertility showed statistically significant association (p<0.001).

CONCLUSION

Knowledge and perception of respondents towards infertility was suboptimal in this study. Some cultural beliefs persist despite the high level of education of respondents. Community-based education on infertility to increase the knowledge and perception of men towards infertility is recommended.

Quality of life of Sudanese patients attending a fertility clinic: a mixed methods study

BACKGROUND

Infertility affects over 50 million people globally, the burden is disproportionately borne by women, especially in low and middle-income countries (LMIC). The impact of infertility on quality of life (QoL) has not been well documented or assessed qualitatively in LMIC like Sudan, where infertility is a pervasive problem. Therefore, the purpose of this mixed-methods study was to assess the fertility-related QoL of infertile individuals in Sudan using the fertility quality of life (FertiQoL) tool.

METHODS

We used explanatory sequential design (surveys and interviews) in a fertility clinic in Sudan (January 2017-May 2018). We collected socio-demographic information, medical/reproductive history and used Arabic FertiQoL. We generated descriptive statistics of FertiQoL (core, domain) scores and independent variables; multiple linear regression models to assess the relationship between FertiQoL and dependent variables; and t-tests to compare mean core/domain scores. We conducted thematic analysis on qualitative data about the subjective experience of being infertile.

RESULTS

The study included 102 participants (72 women), 70 educated beyond secondary school, mean age 33.89 years (SD = 7.82) and mean duration of infertility was 4.03 years (SD 3.29). Mean FertiQoL core score 76.02 (SD = 16.26), domain scores: emotional 71.61 (SD = 22.04), relational 78.06 (SD = 16.62), mind/body 74.06 (SD 22.53) and social 78.88 (SD = 18.24). Men had better fertility-related QoL.

FOUR THEMES EMERGED

A sense of something missing because of childlessness; social pressure from peoples' questions; impact on the spousal relationship (which differed amongst participants) and coping (faith-based and non-faith-based) which was necessary when the lived experience led to internal distress.

CONCLUSIONS

Infertility negatively impacted the QoL of participants in this study, and women were worse off. Cognitive appraisal, social support and pressure may be key factors influencing the QoL of infertile individuals, therefore they should be encouraged to seek social and professional support. FertiQoL is a useful tool to assess fertility QoL in LMIC like Sudan.

Asian Americans and Infertility: Genetic Susceptibilities, Sociocultural Stigma and Access to Care

Infertility affects over 6 million people in the United States and has been shown to disproportionally affect minority patient populations. Asian American infertility is a particularly understudied area of research. This mini review article explores the current state of published research focusing on Asian American infertility trends as well as their barriers to fertility care. A small number of published studies have found that Asian American patients have decreased success with fertility treatments, including lower rates of pregnancy and live birth. These trends may be attributed to a combination of genetic, environmental, and cultural factors, which will be discussed here in further detail. It is crucial to continue building on Asian American fertility research to provide this diverse patient population with comprehensive, compassionate, and culturally sensitive care.

Exploring experiences of infertility amongst women and men in low-income and middle-income countries: protocol for a qualitative systematic review

INTRODUCTION

Infertility is increasingly recognised as a global public health issue for women and men that merits further investigation to support policy and programming. While research in high-income settings has examined the consequences of infertility and access to services, there has been limited synthesis of how individuals experience infertility in low-income and middle-income countries (LMICs). This protocol describes a systematic review that will synthesise qualitative evidence on experiences of infertility among women and men in LMICs.

METHODS AND ANALYSIS

The review will follow the Enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) guidelines for reporting on qualitative evidence syntheses. The study team will search for published literature in PubMed, CINAHL and Scopus and PsycINFO databases and review available grey literature. Using Covidence software, two independent reviewers will conduct title and abstract screening based on inclusion and exclusion criteria, followed by full-text reviews and extraction by a larger team. Quality will be appraised using an adapted version of the Critical Appraisal Skills Programme guidelines. We will conduct thematic synthesis to characterise individual experiences and related factors at the individual, interpersonal, community and health system levels. We will develop a conceptual framework to describe evidence on experiences of infertility in LMICs and to help inform interventions across settings.

ETHICS AND DISSEMINATION

This protocol has been internally approved as exempt by the Institutional Review Board of the Population Council, as it does not involve contact with human subjects or personally identifying data. Results of the review will be published in a peer-reviewed journal and will be used to inform future infertility research and programming in LMICs.

PROSPERO REGISTRATION NUMBER

CRD42021227742.

Levels of anxiety sensitivity, somatosensory amplification and alexithymia in patients with unexplained infertility

OBJECTIVE

In this study, we aimed to focus on the psychological aspect of unexplained infertility by comparing their psychological features to those of infertile patients with a known causes and fertile patients.

PATIENTS AND METHODS

Sixty unexplained infertility patients, 50 infertile patients with a known cause and 56 fertile patients were included in the study. Patients were evaluated using socio-demographic data form, Toronto Alexithymia Scale (TAS-20), Somatosensory Amplification Scale (SAS) and Anxiety Sensitivity Index (ASI-3).

RESULTS

No significant differences in the levels of alexithymia, somatosensory amplification and anxiety sensitivity were detected between the groups (P > .05). When the correlation of clinical scale scores with each other was analysed in the whole group of infertile patients regardless of the cause, a weak positive correlation was found between anxiety sensitivity and difficulty in identifying feelings.

CONCLUSION

In our study, it has been found out that; regardless of the knowledge of the aetiology of infertility, the levels of alexithymia, somatosensory amplification and anxiety sensitivity of infertile cases did not differ from those of fertile women. However, it has been shown that as the difficulty in identifying emotions increases in infertile cases, anxiety sensitivity, which may cause psychological infertility, also increases.

RUBIC (ReproUnion Biobank and Infertility Cohort): A binational clinical foundation to study risk factors, life course, and treatment of infertility and infertility-related morbidity

BACKGROUND

Infertility affects 15%-25% of all couples during their reproductive life span. It is a significant societal and public health problem with potential psychological, social, and economic consequences. Furthermore, infertility has been linked to adverse long-term health outcomes. Despite the advanced diagnostic and therapeutic techniques available, approximately 30% of infertile couples do not obtain a live birth after fertility treatment. For these couples, there are no further options to increase their chances of a successful pregnancy and live birth.

OBJECTIVES

Three overall questions will be studied: (1) What are the risk factors and natural life courses of infertility, early embryonic loss, and adverse pregnancy outcomes? (2) Can we develop new diagnostic and prognostic biomarkers for fecundity and treatment success? And (3) what are the health characteristics of women and men in infertile couples at the time of fertility treatment and during long-term follow-up?

MATERIAL AND METHODS

ReproUnion Biobank and Infertility Cohort (RUBIC) is established as an add-on to the routine fertility management at Copenhagen University Hospital Departments in the Capital Region of Denmark and Reproductive Medicine Centre at Skåne University Hospital in Sweden. The aim is to include a total of 5000 couples equally distributed between Denmark and Sweden. The first patients were enrolled in June 2020. All eligible infertile couples are prospectively asked to participate in the project. Participants complete an extensive questionnaire and undergo a physical examination and collection of biospecimens (blood, urine, hair, saliva, rectal swabs, feces, semen, endometrial biopsies, and vaginal swabs). After the cohort is established, the couples will be linked to the Danish and Swedish national registers to obtain information on parental, perinatal, childhood, and adult life histories, including disease and medication history. This will enable us to understand the causes of infertility and identify novel therapeutic options for this important societal problem.

An mHealth App to Support Fertility Patients Navigating the World of Infertility (Infotility): Development and Usability Study

Background

The experience of infertility and its treatment engenders considerable stress and is often described as an emotional rollercoaster. A mobile health (mHealth) app may be a novel solution to address the psychoeducational and psychosocial support needs of fertility patients because of its potential to reduce stress and increase patient empowerment. There are a few fertility-related apps that provide information and support to both men and women undergoing fertility treatment; however, none have documented their development and evaluation process.

Objective

This study aims to describe the development and evaluation process of a bilingual mHealth app, Infotility, designed to meet the psychoeducational and psychosocial support needs of men and women undergoing fertility treatment.

Methods

To develop the Infotility app, we adhered to the Medical Research Council guidelines for the development and evaluation of complex interventions. First, we conducted literature reviews and needs assessment surveys of fertility patients and health care providers who informed the content and design of the app. Second, we tested the intervention with a small group of end users who provided feedback on the design and appropriateness of the app’s content. Third, we evaluated the uptake and usability of the app using a pre-post study design. Finally, we updated the app’s content based on participants’ feedback and searched for partners to disseminate the app to the broader public.

Results

This study is the first to describe the development and evaluation process of an mHealth app for men and women undergoing fertility treatment. The app met its goal in providing fertility patients with a clinician-approved, portable resource for reliable information about medical and psychosocial aspects of infertility and its treatments and a confidential peer support forum monitored by trained peer supporters. Participants rated the engagement, functionality, information, and esthetics of the app positively, with an overall app quality mean score of 3.75 (SD 0.53) and a star rating of 3.43 (SD 0.75), with a total possible score and star rating of 5.00.

Conclusions

By documenting the systematic development and evaluation of the mHealth app for men and women undergoing fertility treatment, this paper can facilitate the replication of the study intervention and the development of similar mHealth apps.

The pipeline problem: barriers to access of Black patients and providers in reproductive medicine

The demographics of the United States are rapidly changing, and our health care workforce is not keeping pace with the population trends. The American Society for Reproductive Medicine (formerly The American Fertility Society) recognizes the need to increase diversity and is committed to promoting diversity across our membership and leadership as well as promoting equitable quality reproductive care to all patients. In the fall of 2020, the American Society for Reproductive Medicine convened a Diversity, Equity, and Inclusion Task Force to evaluate and make recommendations on the basis of findings to increase diversity to achieve equity and inclusion of reproductive and infertility services for all women. This article focuses on specific barriers that Black or African American patients face in accessing quality care and that provider's face in training and inclusion in reproductive medicine. Multiple publications have confirmed an improvement in health outcome when there is congruence between the patient and the provider. There is a stark contrast between the racial and ethnic diversity of our providers and other support personnel compared with that of our patients. Despite our best intent to minimize the effects of implicit and explicit bias, mistrust and misunderstandings when there is discordance between patients and providers negatively impacts care. To increase provider diversity, it is crucial that we prioritize pipeline programs that recruit and support underrepresented minority in medicine physicians. Specific recommendations are made to increase diversity in the pipeline to improve patient access to culturally competent quality reproductive medicine care with optimal outcomes.

Interpersonal Therapy in Primary Infertility, Life-Cycle Transitions, and Dysthymia: A Single Case Study

Interpersonal psychotherapy (IPT) is an evidence-based therapy, originally developed to treat major depression. IPT conceptualizes depression from a bio-psychosocial perspective where signs of depression are understood in the context of an individual’s current social and interpersonal stressors, defined in terms of role transitions, disputes, bereavements, and sensitivities. In this single case study, IPT was used to treat a woman undergoing primary infertility with multiple failed pregnancies and unsuccessful adoption procedures along with specific grief reactions and depressive symptoms for 2 years. The therapy was formulated over 12 weekly sessions in the outpatient set-up in a general hospital in Kolkata in 2017. Hamilton Depression Rating Scale (HDRS) was used to assess the efficacy of the therapy and its outcomes. The therapy was found to be effective in the patient and justifies the rationale of choosing the said therapy for the specific case from an interpersonal viewpoint. The case study may help suggest how and why to use interpersonal psychotherapy in infertility conditions with psychological ramifications.

Disparities in access to effective treatment for infertility in the United States: an Ethics Committee opinion

In the United States, economic, racial, ethnic, geographic, and other disparities prevent access to fertility treatment and affect treatment outcomes. This opinion examines the factors that contribute to these disparities, proposes actions to address them, and replaces the document of the same name, last published in 2015.

'How did you cope with such concerns?': insights from a monitored online infertility peer support forum

The Research Question posed was 'What coping strategies do fertility patients and trained peer supporters discuss in an online infertility peer support forum?' A thematic analysis was used to examine 244 online posts from a sample of 39 users (37 women and two men) for themes in coping with fertility-related stressors. Data were collected from Connect, a monitored online discussion forum with trained peer supporters. Connect users ranged from 27 to 44 years of age (mean = 34.38) and 33 (84.6%) were nulliparous at the time of the study. A variety of cognitive-reappraisal and practical management coping strategies was discussed across four themes: (i) balancing interpersonal relationships; (ii) partner support; (iii) uncertainty and lack of control; and (iv) positivity and negativity. Experiences of uncertainty and lack of control related to time and schedule, outcomes and waiting for physical symptoms, and the clinic. Connect users commonly discussed the helpfulness of coping strategies. Connect users actively requested experiential information about ways of coping from other patients and peer supporters, highlighting the importance of lived experience to those currently in treatment. Findings support conceptualizations of infertility coping as a process that is unique to the infertility treatment context and that may change throughout a patient's treatment. Trained peer supporters may benefit fertility patients by normalizing, reappraising, and providing practical strategies to ameliorate difficult infertility-related challenges.

Self-efficacy, coping strategies and quality of life in women and men requiring assisted reproductive technology treatments for anatomical or non-anatomical infertility

OBJECTIVE

To examine the magnitude and the predictors of emotional reactions to an infertility diagnosis, comparing women and men who were clinically diagnosed with an anatomical cause of infertility or non-anatomical cause of infertility.

STUDY DESIGN

Cross-sectional study involving a total of 133 adults waiting for infertility treatment at the IVF and Infertility Unit of the S. Orsola University Hospital in Bologna (Italy). Of these, 107 patients (55 with anatomical causes of infertility and 52 with non-anatomical causes of infertility; response rate: 80%) took part to the study. After providing informed written consent, each participant was asked to complete the Infertility Self-efficacy Scale, the Fertility Quality of Life, and the Brief Coping Orientation to Problem Experienced, which they returned at their second access to the Unit. Differences between the groups were analyzed through a series of univariate ANOVA, whereas a multiple regression analysis was used to jointly examine the predictors of fertility quality of life.

RESULTS

Results showed both gender related and diagnosis related differences. Women had statistically significant lower scores than men on the Infertility Self-Efficacy Scale and on the global, emotional, and mind-body subscales of the Fertility Quality of Life, while they scored significantly higher on the emotion focused and socially supported subscales of the Coping Orientation to Problem Experienced. Independently of gender, patients with non-anatomical causes of infertility scored poorly than patients with anatomical causes of infertility on the relational subscale of the Fertility Quality of Life and on the Avoidant scale of the Brief Coping Orientation to Problem Experienced. Hierarchical multiple regression analyses revealed that higher levels of self-efficacy and a lower use of avoidant coping strategies predicted a more positive quality of life over and above gender and cause of infertility.

CONCLUSION

This study partly confirms data on gender differences in experiencing the psychological burden of infertility and adds some new information, particularly with respect to the prediction of quality of life indicators over and above infertility cause.

Infertility After Cancer: How the Need to Be a Parent, Fertility-Related Social Concern, and Acceptance of Illness Influence Quality of Life

BACKGROUND

Adolescents and young adults (AYAs) given a diagnosis of cancer who experience infertility concerns often report having poorer quality of life (QoL). However, the role of infertility-related stressors and illness acceptance on QoL is not clear.

OBJECTIVE

The aim of this study was to describe the impact of psychosocial factors surrounding cancer treatment and infertility on QoL. We hypothesized that need for parenthood and infertility-related social concerns would be directly related to QoL and indirectly related to QoL through acceptance of illness.

METHODS

Cancer patients/survivors (n = 178; 75.3% female) aged 15 to 29 years completed measures of QoL, acceptance of illness, infertility-related social concerns, and need for parenthood. Path analysis was used to test the hypothesized and subsequent models to determine the best fit for predictors of QoL.

RESULTS

The final model explained 28.36% of the variance in QoL. Lower infertility-related social concerns were directly and indirectly related to higher QoL scores. Need for parenthood did not directly relate to QoL, instead relating directly to increased infertility-related social concerns. Higher acceptance of illness (β = .39) and older age (β = .19) were directly related to higher QoL scores. Female patients had higher need for parenthood (β = .17).

CONCLUSIONS

These findings suggest that social concerns and expectations surrounding infertility have a negative impact on AYA cancer survivors' and patients' QoL, which increases as AYAs approach socially normative parenting age.

IMPLICATIONS FOR PRACTICE

Providing survivors with specialist support to manage their infertility-related social concerns and improve their acceptance of illness has the potential to improve their QoL.

Infertility in the Midwest: perceptions and attitudes of current treatment

BACKGROUND

Although infertility affects an estimated 6.1 million individuals in the United States, only half of those individuals seek fertility treatment and the majority of those patients are White and of high socioeconomic status. Research has shown that insurance mandates are not enough to ensure equal access. Many workplaces, schools, and medical education programs have made efforts in recent years to improve the cultural humility of providers in efforts to engage more racially and economically underrepresented groups in medical care. However, these efforts have not been assessed on a population of patients receiving fertility care, an experience that is uniquely shaped by individual social, cultural, and economic factors.

OBJECTIVE

This study aimed to better understand the racial, cultural, economic, and religious factors that impact patient experiences obtaining fertility care.

STUDY DESIGN

A cross-sectional self-administered survey was administered at an academic fertility center in Chicago, Illinois. Of 5000 consecutive fertility care patients, 1460 completed the survey and were included in the study sample. No interventions were used. Descriptive univariate frequencies and percentages were calculated to summarize sociodemographic and other relevant patient characteristics (eg, race or ethnicity, age, household income, religious affiliation, insurance coverage). Rates of endorsing perceived physician cultural competency were compared among demographic subgroups using Pearson chi-squared tests with 2-sided P<.05 indicative of statistical significance. To identify the key determinants of patient-reported worry regarding 9 different fertility treatment outcomes and related concerns, a series of multiple logistic regression models were fit to examine factors associated with patient report of being "very worried" or "extremely worried."

RESULTS

Members of our sample (N=1460) were between 20 and 58 years of age (mean_adjusted, 36.2; standard deviation, 4.4). Among Black participants, 42.3% reported that their physician does not understand their cultural background compared with 16.5% of White participants (P<.0001). Participants who identified as Latinx were significantly more likely than White participants to report being very/extremely worried about side effects of treatment, a miscarriage, ectopic pregnancies, and birth defects (P<.05, P=.02, P=.002, P=.001, respectively). Individuals who identify as Hindu were nearly 4 times more likely to report being very/extremely worried about experiencing an ectopic pregnancy than nonreligious participants (P<.0002). Respondents most strongly identified the biology or physiology of the couple (mean_adjusted, 21.6; confidence interval, 20.4-22.7) and timing or age (mean_adjusted, 27.8; confidence interval, 26.5-29.1) as being associated with fertility. Overall, respondents most strongly disagreed that the ability to bear children rests upon God's will (mean_adjusted, 65.4; confidence interval, 63.7-67.1), which differed most significantly by race (P<.0001) and religion (P<.0001).

CONCLUSION

Of the patient characteristics investigated, racial and ethnic subgroups showed the greatest degree of variation in regard to worries and concerns surrounding the experience of fertility treatment. Our findings emphasize a need for improved cultural humility on behalf of physicians, in addition to affordable psychological support for all patients seeking fertility care.

Infertility Stigma: A Qualitative Study on Feelings and Experiences of Infertile Women

Background:

Infertility stigma is a phenomenon associated with various psychological and social tensions especially for women. The stigma is associated with a feeling of shame and secrecy. The present study was aimed to explore the concept of infertility stigma based on the experiences and perceptions of infertile women.

Materials and Methods:

This qualitative conventional content analysis study was conducted in Isfahan Fertility and Infertility Center, Iran. Data were collected through in-depth interviews with 17 women who had primary infertility. All the interviews were recorded, transcribed and analyzed according to the steps suggested by Graneheim and Lundman. The Standards for Reporting Qualitative Research (SRQR) checklist was followed for this research.

Results:

Eight hundred thirty-six initial codes were extracted from the interviews and divided into 25 sub-categories, 10 categories, and four themes. The themes included “stigma profile, self-stigma, defensive mechanism and balancing”. Stigma profile was perceived in the form of verbal, social and same sex stigma. Self-stigma was experienced as negative feelings and devaluation. Defensive mechanism was formed from three categories of escaping from the stigma, acceptance and infertility behind the mask. Two categories; empowered women and pressure levers, created a balancing theme against the infertility stigma.

Conclusion:

Infertile women face social and self-stigma which threatens their psychosocial wellbeing and self-esteem. They use defensive response mechanisms and social support to mitigate these effects. Education focused on coping strategies might be helpful against infertility stigma.

Infertility-Related Stress and Psychological Health Outcomes in Infertile Couples Undergoing Medical Treatments: Testing a Multi-dimensional Model

The study aims to propose and test a multi-dimensional infertility-related stress model including socio-demographic and fertility-related characteristics, infertility-related stress dimensions, coping strategies and couple's dyadic adjustment dimensions as predictors of anxiety and depression among partners of couples undergoing infertility treatments. Both members of 250 infertile couples filled out a questionnaire consisting of Socio-demographics (Age; Educational level; Employment status), Fertility-related characteristics (Type of diagnosis; Duration of infertility), Fertility Problem Inventory-Short Form, Coping Orientations to Problem Experienced-New Italian Version, Dyadic Adjustment Scale, State-Trait Anxiety Inventory-Y and Edinburgh Depression Scale. Hierarchical Multiple Linear Regressions indicated that the proposed predictive models for anxiety and depression were significant and had good levels of fit with the data. Gender differences emerged in predictor variables. Findings provide valid predictive models that could be adopted to assess psychological health in infertile patients and to develop evidence-based and tailored counselling interventions at centres for assisted reproduction.

Attitudes and Perceptions of Parenthood Among Young Adult Survivors of Childhood Cancer

Purpose: Increasing numbers of childhood cancer survivors enter adulthood and encounter decisions surrounding parenthood. However, limited research has systematically examined how childhood cancer may influence parenthood attitudes among survivors. Methods: Adult survivors of childhood cancer, who had or wanted to have children (N = 77; M_age = 30.2 years, range: 22-43; 91% White), rated their perceived impact of cancer at enrollment and parenthood attitudes using the "Attitudes to Parenthood After Cancer Scale" 2 years later. First, internal consistencies for the parenthood measure were examined, and modified subscales were proposed. Second, hierarchical stepwise regressions analyzed the contribution of background factors and cancer's impact on parenthood attitudes. Results: Reevaluation of parenthood items yielded four subscales with improved internal consistency (α's > .78): improved parenting due to cancer, no children due to cancer, concerns about a (potential) child's health, and parenthood desire irrespective of own health concerns. Already having children (n = 38) was related to more favorable ratings on most subscales. Older age was associated with perceiving improved parenting due to cancer (r = .24) and shorter time since diagnosis was related to considering having no children due to cancer (r = -.23). Hierarchical stepwise regressions reconfirmed parenthood status as related to more favorable parenting attitudes. Cancer preoccupation and perceiving cancer as a most difficult life experience predicted more concerns toward parenthood (R² = .044-.216). Conclusions: Parenthood attitudes were more favorable among survivors with children, who were older, and/or further into survivorship. Survivors burdened by their cancer experience reported more concerns about parenthood. Childhood cancer may shape parenthood perceptions positively and negatively, warranting further research to inform interventions.

Impact of China's zero mark-up drug policy on drug cost of NCDs' outpatients: an interrupted time series analysis

Background

China proposed the Zero Markup Drug Policy (ZMDP), which popularized in tertiary hospitals across the country in 2017, to control drug expenditures’ rapid growth further and reduce the public’s medical burden. This study aims to evaluate the impact of ZMDP on the drug cost of chronic disease outpatients in the tertiary hospital in Chongqing.

Methods

We collected and described the drug-cost data for outpatients with chronic diseases in a Chongqing’s tertiary hospital from 2015 to 2019. The instantaneous and long-term changes of the outpatient volume and average drug cost after the ZMDP were evaluated using interrupted time series (ITS). We also analyzed the policy’s impact under the stratification of gender, age, and basic medical insurance types.

Results

A total of 350,848 outpatients were collected from January 2015 to February 2019. After the ZMDP, the outpatient volume for diabetes, hypertension, and coronary heart disease (CHD) all showed a downward trend, with a decrease of 53.04 (P = 0.012), 142.19 (P < 0.01) and 12.16 (P < 0.001) per month. Simultaneously, the average drug cost decreased by 4.44 yuan (P = 0.029), 5.87 yuan (P < 0.001) and 10.23 yuan (P = 0.036) per month, respectively. By gender, the average drug cost of diabetes in males had the most considerable instantaneous change, reducing by 51.21 yuan (P = 0.017); the decline of CHD in women is the most obvious, with an average monthly decrease of 12.51 yuan (P < 0.001). By age, the instantaneous change of CHD was the greatest for those older than 65 years old, with a decrease of 102.61 yuan (P = 0.030). CHD in 46–65 years old showed the most significant reduction, with an average monthly decline of 11.70 yuan (P < 0.01). BMIUE’s hypertension had the most considerable instantaneous change, which decreased 59.63 yuan (P = 0.010). BMIUE’s CHD showed the most apparent downward trend, with an average monthly decrease of 10.02 yuan (P = 0.010).

Conclusion

The ITS analysis is an effective method of health policy evaluation. The implementation of the ZMDP can reduce the drug cost for chronic disease outpatients in the tertiary hospital and their economic burden. Follow-up policies still require targeted price adjustments in the health service system to adjust the drug cost-effectively.

Infertility, Perceived Certainty of Pregnancy, and Contraceptive Use in Malawi

Infertility and unintended pregnancy are dual burdens in Malawi, where 41% of pregnancies are unintended and approximately 20% of people report infertility. Although preventing unintended pregnancy has been a focus in public health, infertility has rarely been explored as a factor that may be associated with contraceptive use. Using cross-sectional survey data (2017-2018; N = 749), we report on the prevalence of and sociodemographic characteristics associated with infertility and certainty of becoming pregnant among women in Malawi. We conducted multivariable logistic regressions examining the relationship between infertility, certainty of becoming pregnant, and contraceptive use. Approximately 16% of women experienced infertility, and three-quarters (78%) were certain they could become pregnant within one year. Women who experienced infertility had lower odds of contraceptive use than women who did not (Adjusted Odds Ratio [AOR]: 0.56; 95% Conficence Interval [CI]: 0.39-0.83). Women who said there was "no chance" or they were "unlikely" to become pregnant also had lower odds of contraceptive use compared to women who were certain they would become pregnant (AOR: 0.30; 95% CI: 0.10-0.92). Our findings indicate that experiences and perceptions surrounding fertility are associated with contraceptive use, underscoring their importance in understanding how people manage their fertility to reach their reproductive goals.

[Effects of First Assisted Reproductive Technologies on Anxiety and Depression among Infertile Women: A Systematic Review and Meta-Analysis]

PURPOSE

The purpose of this study was to analyze anxiety and depression among infertile women at different time points during the first In Vitro Fertilization (IVF) or Intracytoplasmic Sperm Injection (ICSI) treatment through a systematic review and meta-analysis.

METHODS

Seven out of 3,011 studies were included for meta-analysis. To estimate the effect size, a meta-analysis of the studies was performed using the RevMan 5.3 program. We compared the measurement outcomes at three time points: before the start of treatment (T0), cancellation of treatment after pregnancy detection (T2), one to six months after treatment (T3). The effect size used was the standardized mean difference (SMD).

RESULTS

In comparing the different time points of the pregnant women from their cycle, significantly lower levels of depression were found at T2 than at T0. In non-pregnant women, anxiety at T2 and depression at T2 and T3 were significantly higher than those at T0. At T2 and T3, the non-pregnant women reported higher levels of anxiety and depression compared with the pregnant women.

CONCLUSION

Anxiety and depression in infertile women undergoing the first IVF or ICSI are associated with the time points and pregnancy status after treatment. These findings suggest that attention should be paid to helping infertile women prepare for and cope with treatment and treatment failure.

Family resilience is a protective buffer in the relationship between infertility-related stress and psychological distress among females preparing for their first in vitro fertilization-embryo transfer

The present study aimed to evaluate psychological distress and scrutinized whether family resilience plays a moderating role in the association between infertility-related stress and psychological distress among infertile females preparing for their first IVF-ET. A total of 492 infertile females completed self-reported measures including the Kessler 10 Psychological Distress Scale (K10), the fertility problem inventory (FPI), and the Family Resilience Assessment Scale (FRAS). The results showed 21 (65.2%) participants reported moderate or higher levels of psychological distress. While controlling for economic status, we found psychological distress to be positively linked to infertility-related stress (β=0.483, P<0.001), and negatively related to family resilience (β=-0.145, P=0.001). The simple slopes analysis showed that infertility-related stress had a weaker positive association with psychological distress for individuals at 1 SD (β = 0.443, P < 0.001) above the mean on family resilience compared to those at 1 SD (β = 0.537, P < 0.001) below the mean. Thus, it suggests that clinical practice should conduct family resilience-oriented interventions to facilitate family resilience among infertile females preparing for their first IVF-ET, with the goal to reduce psychological distress.

Childless by circumstance - Using an online survey to explore the experiences of childless women who had wanted children

Childlessness is increasing globally. This study aimed to explore the experiences of childless women who had wanted children. An online survey study was promoted through social media to recruit women aged ≥46 years who were childless by circumstance. The survey remained open for 15 days. In total, 303 survey responses were collected, 176 of which were complete surveys. In total, 15.3% (27/176) of women who had wanted children reported that they had not tried to have children, most commonly due to the lack of a partner (40.7%, 11/27). Of the 139 women who had tried to have children, 70.5% (98/139) had used calendar-based menstrual cycle tracking methods to identify their fertile window, and many had undergone fertility checks including hormone tests (75.5%, 105/139) and ultrasound scans (71.2%, 99/139). A significant proportion of women had experienced a miscarriage (40.2%, 56/139). Many women had decided not to have any fertility treatment (43.2%, 60/139). For those who did, the majority had tried in-vitro fertilization (74.6%, 59/79). The most common reason that women gave for stopping fertility treatment was due to emotional reasons (74.7%, 59/79). When asked how women felt now about their childlessness, the most common issues identified were unhappiness (85/158, 54%), acceptance (43/158, 27%) and happiness (30/158, 19%). There should be more support for unsuccessful fertility patients and other childless women, and more emphasis should be placed upon fertility education in order to ensure that women are better informed about fertility issues.

Estimating the government public economic benefits attributed to investing in assisted reproductive technology: a South African case study

Limited resources and high treatment costs are arguments often used in many public health systems in low- and middle-income countries to justify providing limited treatments for people with infertility. In this analysis, we apply a government public economic perspective to evaluate public subsidy for in-vitro fertilization (IVF) in South Africa. A fiscal model was developed that considered lifetime direct and indirect taxes paid and government transfers received by a child conceived by IVF. The model was constructed from public data sources and was adjusted for mortality, age-specific educational costs, participation in the informal economy, proportions of persons receiving social grants, and health costs. Based on current proportions of individuals receiving social grants and average payments, including education and health costs, we estimate each citizen will receive ZAR513,165 (USD35,587) in transfers over their lifetime. Based on inflated age-specific earnings, we estimate lifetime direct and indirect taxes paid per citizen of ZAR452,869 (USD31,405) and ZAR494,521 (USD34,294), respectively, which also includes adjustments for the proportions of persons participating in the informal economy. The lifetime net tax after deducting transfers was estimated to be ZAR434,225 (USD31,112) per person. Based on the average IVF investment cost needed to achieve one live birth, the fiscal return on investment (ROI) for the South African Government is 5.64. Varying the discount rate from 4% to 7%, the ROI ranged from 9.54 to 1.53, respectively. Positive economic benefits can emanate from public financing of IVF. The fiscal analytic framework described here can be a useful approach for health services to evaluate future public economic benefits.

IVF, acupuncture and mental health: a qualitative study of perceptions and experiences of women participating in a randomized controlled trial of acupuncture during IVF treatment

Infertility treatments such as in-vitro fertilization (IVF) are stressful and challenging to mental health and well-being. The use of alternative therapies adjunct to IVF treatment, such as acupuncture, is common and women hope to improve their chance of pregnancy and live birth. While many women engage in acupuncture adjunct to IVF in Australia, few qualitative studies of women's motivations and experiences have been conducted in this field. A qualitative study was nested within a randomized controlled trial of acupuncture during IVF treatment in order to explore women's perceptions of acupuncture, its effects in the context of IVF treatment, and how acupuncture is perceived in relation to the outcome of IVF. Fifty women randomized into both acupuncture and sham acupuncture groups were interviewed using a semi-structured format. In-depth interviews were transcribed, coded and categorized in a theoretical thematic analysis. Two primary themes emerged: 'psychological benefit' and 'perceived influence of acupuncture on fertility/medical outcome'. Regardless of randomization, women in both groups described similar psychological effects suggesting that a placebo effect was present. They were not convinced that acupuncture could enhance their treatment outcome through biomedical pathways. Rather, they perceived that acupuncture or sham acupuncture gave them a psychological advantage through increased relaxation, reduced psychological stress, and enhanced well-being and self-efficacy. In conclusion, there are significant features associated with a placebo effect in acupuncture that might be exploited to provide psychological benefit for women undertaking IVF.

The Prevalence of Ureaplasma Urealyticum and Mycoplasma Hominis Infections in Infertile Patients in the Northeast Region of Romania

Background and objectives: Ureaplasma urealyticum (UU) and Mycoplasma hominis (MH) are two commensal microorganisms that form the urogenital microbiota. Under a state of dysbiosis, both bacteria cause intrauterine infection. Material and methods: Therefore, the purpose of the present study was to analyze the prevalence of UU and MH among four hundred and eleven infertile women. Results: Women between thirty and thirty-five years old were the most affected group, followed by those that were 25 and 30 years old, respectively. Cumulatively, the prevalence of single UU and MH, and coinfection, was 28.46% (n = 117), (n = 2) 0.48%, and 2.91% (n = 12), respectively, with an overall detection rate of 31.87% (n = 131). To assess the associated drug susceptibility, endocervical samples were unequally sent to Regina Maria (n = 281) and Synevo (n = 130) laboratories for further analyses. Pristinamycin (100% vs. 100%) and Josamycin (100% vs. 98.00%) were the most efficient antibiotics in eradicating UU and MH, several others also displaying a high efficiency, among which can be mentioned Doxycycline (98.23%), Minocycline (96.00%), Tetracycline (96.48% vs. 68.00%), and Erythromycin (70.17% vs. 92.00%). Based on antibiograms, Clarithromycin (88.00%), Roxithromycin (88.00%), Levofloxacin (82.00%), and Azithromycin (78.94%) can be further used in treating such infections. On the other hand, Clindamycin (4.00%) and Ciprofloxacin (12.27% vs. 2.00%) are no longer viable because both UU and MH display an intermediate response towards gained resistance. Interestingly, the efficiency of Ofloxacin (22.79% vs. 60.00%) was conflicting, this possibly suggesting a transient stage to a gradual adaptability of these microorganisms to Ofloxacin. Conclusions: The most susceptible age groups in each case were women that were between twenty and forty years old. It can be concluded that four antibiotics can be safely used for treating UU, MH, or dual infections whose efficiency was over 95%.

Psychological experience and coping strategies of patients in the Northeast US delaying care for infertility during the COVID-19 pandemic

BACKGROUND

On March 17, 2020 an expert ASRM task force recommended the temporary suspension of new, non-urgent fertility treatments during an ongoing world-wide pandemic of Covid-19. We surveyed at the time of resumption of fertility care the psychological experience and coping strategies of patients pausing their care due to Covid-19 and examined which factors were associated and predictive of resilience, anxiety, stress and hopefulness.

METHODS

Cross sectional cohort patient survey using an anonymous, self-reported, single time, web-based, HIPPA compliant platform (REDCap). Survey sampled two Northeast academic fertility practices (Yale Medicine Fertility Center in CT and Montefiore's Institute for Reproductive Medicine and Health in NY). Data from multiple choice and open response questions collected demographic, reproductive history, experience and attitudes about Covid-19, prior infertility treatment, sense of hopefulness and stress, coping strategies for mitigating stress and two validated psychological surveys to assess anxiety (six-item short-form State Trait Anxiety Inventory (STAl-6)) and resilience (10-item Connor-Davidson Resilience Scale, (CD-RISC-10).

RESULTS

Seven hundred thirty-four patients were sent invitations to participate. Two hundred fourteen of 734 (29.2%) completed the survey. Patients reported their fertility journey had been delayed a mean of 10 weeks while 60% had been actively trying to conceive > 1.5 years. The top 5 ranked coping skills from a choice of 19 were establishing a daily routine, going outside regularly, exercising, maintaining social connection via phone, social media or Zoom and continuing to work. Having a history of anxiety (p < 0.0001) and having received oral medication as prior infertility treatment (p < 0.0001) were associated with lower resilience. Increased hopefulness about having a child at the time of completing the survey (p < 0.0001) and higher resilience scores (p < 0.0001) were associated with decreased anxiety. Higher reported stress scores (p < 0.0001) were associated with increased anxiety. Multiple multivariate regression showed being non-Hispanic black (p = 0.035) to be predictive of more resilience while variables predictive of less resilience were being a full-time homemaker (p = 0.03), having received oral medication as prior infertility treatment (p = 0.003) and having higher scores on the STAI-6 (< 0.0001).

CONCLUSIONS

Prior to and in anticipation of further pauses in treatment the clinical staff should consider pretreatment screening for psychological distress and provide referral sources. In addition, utilization of a patient centered approach to care should be employed.

'I felt less alone knowing I could contribute to the forum': psychological distress and use of an online infertility peer support forum

Background

Feelings of loss, shame and stigmatization, reduced quality of life, isolation and loneliness are common among men and women with infertility. Fertility patients may seek peer mentoring and support, specifically through the use of online forums, to fulfil their needs for shared experience and guidance through the fertility treatment process.

Objective

To assess the use and benefits of an online fertility-related peer support forum through two research questions: (1) do socio-demographics, stress, and anxiety differ between posters on the forum, lurkers who read messages but did not post, and people who chose not to use it?; and (2) how did forum users describe their experiences?

Design

A sample of 220 male and female fertility patients aged 23–54 years old (M = 35.51, SD = 4.94) were recruited at fertility clinics in Montreal and Toronto, Canada, to test a mobile application called ‘Infotility’. They answered questionnaires before and after being given access to Infotility for eight weeks. The peer support forum was accessible through the Infotility dashboard.

Main Outcome Measures

Psychological distress was measured through the 4-item Perceived Stress Scale and the Generalized Anxiety Disorder 7-item Scale. Experiences using the forum were assessed through open-ended questions and in-depth interviews.

Results

Participants with heightened psychological distress were more likely to become posters rather than lurkers or non-users and reported less distress after using the forum. Forum users appreciated the opportunity to share their experiences with others in similar situations.

Conclusion

The forum reduced loneliness and allowed participants to learn new ways to manage stress. It was particularly beneficial for those with heightened psychological distress.

Mini-Review Regarding the Applicability of Genome Editing Techniques Developed for Studying Infertility

Infertility is a highly debated topic today. It has been long hypothesized that infertility has an idiopathic cause, but recent studies demonstrated the existence of a genetic substrate. Fortunately, the methods of editing the human genome proven to be revolutionary. Following research conducted, we identified a total of 21 relevant studies; 14 were performed on mice, 5 on zebrafish and 2 on rats. We concluded that over forty-four genes in total are dispensable for fertility in both sexes without affecting host homeostasis. However, there are genes whose loss-of-function induces moderate to severe phenotypic changes in both sexes. There were situations in which the authors reported infertility, exhibited by the experimental model, or other pathologies such as cryptorchidism, cataracts, or reduced motor activity. Overall, zinc-finger nucleases (ZFNs), transcription activator-like effector nucleases (TALENs), and clustered regularly interspaced short palindromic repeat (CRISPR)/Cas9 are techniques that offer a wide range of possibilities for studying infertility, even to create mutant variants. It can be concluded that ZFNs, TALENs, and CRISPR/Cas9 are crucial tools in biomedical research.

Involuntary Childlessness and Marital Infidelity Among Women in Sub-Saharan African Countries: An Assessment of the Moderating Role of Women's Education

A considerable number of married women in sub-Saharan African countries are childless and may be likely to engage in marital infidelity to avoid social stigma, economic insecurities, and other debilitating experience associated with being involuntarily childless. This study sought to investigate the relationship between involuntary childlessness and marital infidelity and how it may be moderated by women's educational attainment. Data were obtained from 23,847 women in their first union for at least 2 years and participated in the demographic and health surveys of five sub-Saharan African countries comprising Cameroon, Gabon, Lesotho, Liberia, and Sierra Leone. Data were analyzed using multivariate logistic regression, adjusted for socioeconomic, union, and partner characteristics. Involuntarily childless women in Cameroon (AOR: 2.34, 95% CI 1.62-3.39) and Sierra Leone (AOR: 2.22, 95% CI 1.42-3.49) were about two times more likely to engage in marital infidelity compared to non-childless married women. In Gabon, Lesotho, and Liberia, the odds of marital infidelity did not significantly differ between involuntarily childless and non-childless married women. Although involuntarily childless women with secondary or higher education reported higher levels of marital infidelity than non-childless women with a similar level of education, we found no statistical evidence in all the countries that the relationship between involuntary childlessness and marital infidelity was moderated by women's educational attainment. These findings suggest that involuntary childlessness is a critical factor potentially related to marital infidelity and may be an important target for intervention and prevention, particularly in settings with high levels of sexually transmitted infections.

The Need of Personalized Medicine in Coping with Stress during Infertility Treatment

The term personalized medicine was created for oncological patients, but due to its positive clinical results it is now used in many other fields of medicine, including reproductive medicine. The aim of the study was to determine the level of stress and strategies of coping with stress in patients treated for infertility. The study—using a questionnaire developed by the authors, the Perceived Stress Scale-10 (PSS-10), and the Coping Orientation to Problems Experienced Inventory (Mini-COPE)—was conducted among 456 people from infertile couples. Conclusions: More than half of the studied patients demonstrated a high level of stress. The choice of coping strategies was related to the respondents’ gender and level of stress as well as their experience with assisted reproductive technology.

Reflections on autonomy in travel for cross border reproductive care

Travel for reproductive health care has become a widespread global phenomenon. Within the field, the decision to travel to seek third parties to assist with reproduction is widely assumed to be autonomous. However there has been scant research exploring the application of the principle of autonomy to the experience of the cross-border traveller. Seeking to contribute to the growing, but still small, body of sociological bioethics research, this paper maps the application of the ethical principle of autonomy to the lived experience of infertile individuals who cross borders for reproductive care. It examines their choices as patient, consumer and traveller. It suggests that their experience evidences a contradictory autonomy, which offers them both choice and no choice in their final decision to travel. The paper argues that this lack of meaningful autonomy is enabled by a medicalised framework of infertility which prioritises technology as the cure to infertility. This both shapes expectations of infertile individuals and limits their options of family creation. Ultimately, the paper suggests that sociological bioethics research shows that the liberatory credentials of technology should be questioned, and identifies that this field demands greater scholarly attention.

Fertility patients under COVID-19: attitudes, perceptions and psychological reactions

STUDY QUESTION

What are the perceptions of infertility patients and the factors correlating with their psychological distress, following suspension of fertility treatments during the Corona Virus Disease-19 (COVID-19) pandemic?

SUMMARY ANSWER

Most patients preferred to resume treatment given the chance regardless of background characteristics; higher self-mastery and greater perceived social support were associated with lower distress, while feeling helpless was associated with higher distress.

WHAT IS KNOWN ALREADY

Infertility diagnosis and treatment frequently result in significant psychological distress. Recently published data have shown that clinic closure during the COVID-19 pandemic was associated with a sharp increase in the prevalence of anxiety and depression among infertile patients undergoing IVF and was perceived as an uncontrollable and stressful event. Personal resources play an important protective role in times of crisis, helping reduce levels of distress.

STUDY DESIGN, SIZE, DURATION

This cross-sectional questionnaire study included patients whose fertility treatment was suspended following the COVID-19 pandemic, in a tertiary hospital. The survey was delivered to 297 patients within 12 days at the beginning of April 2020.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The self-administered questionnaire included items addressing: (i) patients' demographic characteristics, (ii) anxiety related to COVID-19 infection risk and level of social support, (iii) patients' perceptions of the new guidelines and description of subsequently related emotions and (iv) two validated scales assessing levels of emotional distress and self-mastery. Multivariate analysis was conducted to assess factors alleviating or increasing emotional distress during the COVID-19 pandemic.

MAIN RESULTS AND THE ROLE OF CHANCE

There were 168 patients who completed the survey, giving a response rate of 57%. Study variables in the regression model explained 38.9% of the variance in psychological distress experienced by patients during treatment suspension. None of the background characteristics (e.g. age, marital status, parity, economic level or duration of treatments) had a significant contribution. Feeling helpless following the suspension of treatments was associated with higher distress (P < 0.01). Higher self-mastery and greater perceived social support were associated with lower distress (P < 0.01). Despite the ministry of health's decision, 72% of patients wished to resume treatment at the time of survey.

LIMITATIONS, REASONS FOR CAUTION

This was a cross-sectional study, thus information about patients' characteristics prior to the COVID-19 pandemic was not available. The length and implications of this pandemic are unknown. Therefore, the ability to draw conclusions about the psychological consequences of the crisis is limited at this point of time.

WIDER IMPLICATIONS OF THE FINDINGS

Personal resources play an important protective role in times of crisis, helping to reduce levels of distress. Study findings suggest that attention should be paid to strengthening and empowering patients' personal resources together with directly confronting and containing feelings of helplessness. In line with the European Society for Human Reproduction and Embryology (ESHRE) guidelines, especially at this time of high levels of distress, it is imperative to offer emotional support to reduce stress and concerns. Furthermore, as the pandemic is stabilizing, resumption of treatment should be considered as soon as appropriate according to local conditions.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the IVF unit of the Shamir Medical Center. All authors declare no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Is a dyadic stressor experienced as equally distressing by both partners? The case of perceived fertility problems

Using data from a population survey, this article explores whether perceptions of having a fertility problem among 926 U.S. couples in heterosexual relationships (women aged 25-45 and male partners) are associated with distress. Most couples did not perceive a fertility problem (58%). In almost a third (30%) of the couples, only women perceived a fertility problem; in 4%, only the men; and in nearly a fifth (19%), both perceived a problem. Adjusted for characteristics associated with fertility problems and depressive symptoms, those who perceived a problem exhibited significantly more depressive symptoms than those who did not. Fertility problems are sometimes experienced as individual because in some couples only one partner perceives a problem or has higher distress in response to their own rather than to their partners' perceived problems. For women, fertility problems are experienced as a couple phenomenon because women were more distressed when both partners perceive a problem. The perception of fertility problems is gendered in that women were more likely to perceive a problem than men. Furthermore, men are most distressed when they perceive a problem and their partner does not.

Supportive care: men's expectations who undergoing in vitro fertilization treatment

Objective

Infertile couples perceive some needs and expectations during treatment. Most studies have focused on infertile women’s needs. The study was done to explore the expectations of men who undergoing in in vitro fertilization (IVF) treatment. Participants were men whose wives undergo IVF treatment in the IVF clinic of Shahid Motahhri hospital in Urmia. Purposive sampling was performed and data collection was done through in-depth semi-structured interviews until data saturation.

Results

“Supportive care” was emerged as the main theme consisted of two categories. The first category was “to be treated with attention in healthcare setting” which included three subcategories: Receiving couple based care, establishing counseling centers, and continuous care. The second category was “to be welcomed in the society” which included two subcategories: Financial support from community and close family, and changing community views about IVF treatment. Expectations of men undergoing IVF focuses on supportive care. They seek to receive the kind of care from health care setting and society. A deep understanding of the needs could help practitioners to consider men’s expectations, and assist policy makers and researchers to design and implement interventions and programs in infertility clinics which enhance the partnership of infertile men and fulfill their expectations.

Risk factors for resignation from work after starting infertility treatment among Japanese women: Japan-Female Employment and Mental health in Assisted reproductive technology (J-FEMA) study

OBJECTIVE

To elucidate the risk factors associated with resignation from work of Japanese women undergoing infertility treatment.

METHODS

A total of 1727 female patients who attended a private fertility clinic in Japan participated in the Japan-Female Employment and Mental health in Assisted reproductive technology study. Questions related to demographic, clinical and socioeconomic characteristics were employed in the questionnaire. Out of the 1727 patients, 1075 patients who were working at the time of initiating infertility treatment and felt infertility treatment incompatible with work were included in the analysis. Risk factors for resignation were assessed by using multivariable logistic regression models.

RESULTS

Among 1075 working women who started infertility treatment, 179 (16.7%) subsequently resigned. Multivariable-adjusted ORs for resignation in those with lower educational background and infertility for ≥2 years were 1.58 (95% CI: 1.07 to 2.34) and 1.82 (95% CI: 1.15 to 2.89), respectively. The OR for resignation in non-permanent workers undergoing infertility treatment was 2.65 (95% CI: 1.61 to 4.37). While experiencing harassment in the workplace approached significance, lack of support from the company was significantly associated with resignation after starting infertility treatment, with ORs of 1.71 (95% CI: 0.98 to 2.99) and 1.91 (95% CI: 1.28 to 2.86), respectively.

CONCLUSION

One-sixth of women resigned after starting infertility treatments. It was found that factors related to education, infertility duration and work environment were significantly associated with resignation. Reducing the physical and psychological burden endured by women, for example, by increasing employer-provided support, is vitally important in balancing infertility treatment with maintenance of work life.