Subfertile couples' negative experiences with intrauterine insemination care

The impact of IVF patients' characteristics on their satisfaction and quality-of-life with overseas treatment: A mixed methods approach

Recent advances in infertility therapy, such as hormone medication and in vitro fertilization (IVF), have led to an increase in the demand for IVF. North Cyprus is a new medical tourist destination, and this study aimed to discover influential demographic predictors of IVF patients' satisfaction and quality-of-life (QoL) after receiving reproductive IVF services. Two questionnaires on IVF patient satisfaction and QoL were administered to 101 patients who received services in selected IVF clinics. Parametric and nonparametric tests were used for statistical analysis. The results showed that the mean satisfaction level with IVF service introduction and doctor professionalism increased with age, and a maximum satisfaction level was found in older patients. Doctor professionalism was another significant factor for greater satisfaction in older patients than in young patients who underwent IVF treatment. Satisfaction with IVF services was reduced by increasing education levels. IVF services must be managed and provided based on the needs of patients from different demographic backgrounds and efforts must be made to improve satisfaction with fertility services.

From generalist to specialist: A qualitative study of the perceptions of infertility patients

Few studies explore in-depth accounts of women's and men's experiences with, and transitions between, obstetrician/gynaecologists (OB/GYNs) and reproductive endocrinologists during infertility diagnostic and treatment processes. This study examined this subject matter with data from qualitative, in-depth, semi-structured interviews. Between April 2007 and March 2008, the first author interviewed 20 women and eight men from a large midwestern metropolitan area in the USA who had used, or were in the process of using, any fertility treatment in the 5 years preceding the interview. Six couples and 16 individuals were interviewed, resulting in narratives of 22 distinct infertility journeys. The main complaints made by respondents about OB/GYNs were that they were insufficiently concerned with providing timely treatment and that they paid insufficient attention to male partners. Women felt that their concerns were taken more seriously by reproductive endocrinologists, but complained of insensitivity, depersonalization and misinformation, and were suspicious of a profit orientation.

A systematic review and secondary analysis of two studies identifying demographic and medical characteristics determining patient-centeredness in endometriosis care as experienced by patients

STUDY QUESTION

What are the patient-specific determinants associated with patient-centered endometriosis care as measured by the ENDOCARE questionnaire (ECQ)?

SUMMARY ANSWER

‘Overall grade for endometriosis care’, ‘educational level’, ‘membership of a patient organization’ and ‘having seen other specialists for endometriosis complaints’ are correlated with overall patient-centeredness scores (PCS).

WHAT IS KNOWN ALREADY

Patient-centeredness of endometriosis care can be evaluated using the validated ECQ. The ECQ leads to an overall PCS and separate PCS for 10 dimensions of endometriosis care. Previously, educational level and quality of life scores were found to be associated with ECQ results.

STUDY DESIGN, SIZE, DURATION

First, a systematic literature review was performed (PROSPERO registration number: CRD42020169872). MEDLINE, Cochrane CENTRAL and EMBASE databases were searched from inception to May 2020 for studies in any language reporting on the results of the ECQ in patients with endometriosis. Two studies were identified. From the two studies, all original data were merged. In total, data from 546 patients were available for analysis. Second, univariate and multivariate regression analyses were performed to identify determinants for patient-centeredness of endometriosis care.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The two included studies evaluated patient-centeredness in four endometriosis care centers in Belgium and the Netherlands. All participants had surgically proven endometriosis. Possible patient-specific determinants were selected from the demographic and medical questions from the first part of the ECQ. These determinants were evaluated using linear regression analysis and all possible determinants with a P > 0.2 in the univariate analysis were selected for stepwise multivariate analysis. Separate analyses were performed for overall PCS and each of the 10 dimensions.

MAIN RESULTS AND THE ROLE OF CHANCE

The two included studies provided data from 546 patients. After adjustment for care center, multivariate analysis showed that a higher ‘grade for endometriosis care’ (B = 0.66), a ‘lower educational level’ (B = 0.50), ‘being member of a patient organization’ (B = 0.49) and ‘having seen other specialists for endometriosis complaints’ (B = 0.34) were independently associated with higher overall PCS (R² = 0.41). ‘Grade for endometriosis care’ was a determinant for all dimensions of endometriosis care. ‘Having seen other specialists for endometriosis complaints’ was positively associated with the care dimensions ‘respect for patients’ values, preferences and expressed needs’, ‘continuity and transition’ and ‘technical skills’. Members of a patient organization showed higher scores on the care dimensions ‘emotional support and alleviation of fear and anxiety’, ‘continuity and transition’ and ‘endometriosis clinic staff’. Furthermore, we found that having a higher level of education is associated with lower scores in the care dimensions ‘physical comfort’, ‘emotional support and alleviation of fear and anxiety’ and ‘involvement of significant other’.

LIMITATIONS, REASONS FOR CAUTION

These results delineate the patient-specific determinants of patient-centered care as measured using the Dutch ECQ. Whether results are generalizable to other countries should be investigated in an international study. This requires the ECQ to be validated in other languages first.

WIDER IMPLICATIONS OF THE FINDINGS

The aforementioned determinants of patient-centered care are of value for studies benchmarking clinics for their patient-centeredness. In addition, they help clinicians to determine how to tailor their care to individual patients. At every visit, patients could be asked to grade the endometriosis care (on a scale of 0–10) to easily investigate patient-centeredness. When there is more time, women with endometriosis should be asked to complete the entire ECQ to investigate patient-centeredness in depth.

STUDY FUNDING/COMPETING INTEREST(S)

The department of reproductive medicine (involving C.B.L. and V.M.) of the Amsterdam UMC, Vrije Universiteit Amsterdam has received several research and educational grants from Guerbet, Merck and Ferring. The authors have no conflict of interest related to this manuscript.

Patient perceptions and understanding of treatment instructions for ovarian stimulation during infertility treatment

The impact of patient-physician communication and levels of understanding of treatment on patient knowledge and compliance has been studied in patients undergoing their first cycle of infertility treatment. This observational, real-life, longitudinal study involved 488 patients from 28 infertility centres in France. Data on communication quality, understanding of treatment instructions, patient knowledge and compliance to treatment protocol were collected through questionnaires administered before treatment initiation (V1) and at oocyte retrieval (V2). At V1, patients were very satisfied with their levels of understanding of the injection and monitoring schedules, the information given by the medical team, and the way of receiving instructions, with average ratings on a scale of 0-100% of > 75%. They rated their understanding of possible treatment side-effects as satisfactory (average score 71.1%). Gaps in patient knowledge about their treatment, revealed by discrepancies between physician and patient reports, were observed in 20.5% of patients (n = 79/386), and most commonly resulted from confusion about the units and dose of gonadotropin. Anxiety about performing self-injections and a lack of confidence in their ability to self-inject correctly were each observed in approximately one-third of patients. Patient self-assessment of compliance at V2 revealed that 27% of patients (n = 83/305) did not comply with or had doubts about the injection schedule or dose injected. Meanwhile physicians reported high levels of patient compliance (94.3%; n = 350/371). In conclusion, even when patient-physician relationships appear to be satisfactory, patient miscomprehension and non-compliance during infertility treatment may be underestimated. Further interventions are required to improve these outcomes.

Doctor-couple communication during assisted reproductive technology visits

STUDY QUESTION

What are the characteristics of doctor-couple communication content during actual ART visits?

SUMMARY ANSWER

Physicians were mainly focused on providing biomedical information, while communication content from couples had a 2-fold focus on providing biomedical information and on positive talk.

WHAT IS KNOWN ALREADY

Communication aspects in ART seem crucial for clinical decision-making, retention in care and critical conversations with couples due to low treatment success rates. However, no studies have been carried out on the actual interaction between the doctor and the couple in this context.

STUDY DESIGN, SIZE, DURATION

This observational study involved 28 clinicians and 160 patients referred to eight Italian ART clinics during a one-year recruitment period.

PARTICIPANTS/MATERIALS, SETTING, METHODS

ART visits at eight Italian clinics were videotaped. The visits were coded using the Roter Interaction Analysis System (RIAS), particularly focusing on RIAS composite categories, verbal dominance and patient-centeredness score.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 85 visits were eligible for analysis (62% acceptance rate), involving 28 clinicians and 160 patients (including 75 couples). The average visit duration was 37 ± 17.7 min. The mean verbal dominance was 1.9 ± 0.86 (range: 0.72-5.74). Physicians mainly focused on providing biomedical information. Communication content from couples had a 2-fold focus on providing biomedical information and on positive talk. The mean of patient centeredness index (PCI) was 0.51 (SD = 0.28; range 0.08-1.77); visits in which the doctor was a woman or the treatment indication was for heterologous fertilization showed higher PCI scores. Overall, females accounted for 67% of all patient talk. Taking this imbalance into account as expected frequencies for each composite category, males reported significantly more utterances in almost all of the socioemotional categories.

LIMITATIONS, REASONS FOR CAUTION

These results are preliminary and observational and only regard Italy. Communication during visits may have been biased since the professionals who agreed to participate showed an interest in communication issues. Another limitation is a possible Hawthorne effect due to the fact that participants were aware of being videotaped.

WIDER IMPLICATIONS OF THE FINDINGS

Our study showed that ART physicians mainly adopted an informative model of communication and a more disease-oriented approach. Findings revealed the complexity of communication content during ART consultations, given its triadic characteristic in which the third party is also a patient; clinicians should be aware of this complex aspect and of the specific male and female perspectives to be taken into account. The results could be useful for training ART professionals.

STUDY FUNDING/COMPETING INTEREST(S)

This study was possible thanks to an unconditional grant from Ferring Spa to the Department of Health Sciences, University of Milan. There are no competing interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

In vitro fertilization healthcare professionals generally underestimate patients' satisfaction with quality of care

INTRODUCTION

Previous studies have mainly compared professionals' and patients' ratings of the importance of different care aspects, finding poor agreement between the groups concerning patient-centered quality of care. There is still little known about professionals' knowledge of how patients experience the quality of care they receive during in vitro fertilization (IVF) treatments. The aim of this study was to investigate how IVF healthcare professionals estimate patients' experience of patient-centered quality of care and if certain factors influenced the IVF professionals' perceptions and IVF patients' experience of quality of care.

MATERIAL AND METHODS

All 16 IVF public and private clinics in Sweden participated in this cross-sectional study. A total of 268 IVF healthcare professionals and 3298 patients (women and men) undergoing IVF treatment between January and May 2015 participated by answering the validated questionnaire "Quality from the patients' perspective of in vitro fertilization treatment" (QPP-IVF).

RESULTS

Healthcare professionals significantly underestimated patients' satisfaction with the patient-centered quality of care they received in all aspects measured. Both patients and professionals rated the most deficient factors to be "responsibility/continuity", "participation" and "availability". Healthcare professionals and patients belonging to private clinics evaluated patient-centered care as significantly better than professionals and patients at public clinics in almost all aspects measured.

CONCLUSION

The results of this study will increase the professionals' understanding of the patients' experiences during IVF treatment and provide additional knowledge when identifying areas to prioritize to improve quality of care.

Satisfaction with in vitro fertilization treatment: patients' experiences and professionals' perceptions

BACKGROUND

This paper investigates patients' satisfaction with various aspects of fertility care and seeks to determine to what extent fertility specialists are able to assess patient satisfaction. Patients' experiences with in-vitro fertilization (IVF) services and facilities have been compiled and examined in order to discover whether patients' satisfaction is correlated to psychological factors and demographic, socio-economic, and health characteristics, and whether patients' satisfaction has an influence on the willingness to pay (WTP) for IVF treatment.

METHODS

The study was carried out on 204 patients and 19 fertility professionals from 8 public IVF units in Israel.

RESULTS

The study found that, overall, infertile patients are satisfied with the care they received. Several demographic variables (age; education; income; number of fertility treatments) and psychological factors ('Pessimism' and 'Activeness'), were found to be significantly correlated with patient satisfaction with IVF. The results yielded a negative correlation between the WTP for IVF treatment and the satisfaction with access to care and physical conditions.

CONCLUSIONS

Patient satisfaction is an important component in the evaluation of fertility treatments as well as other medical interventions. Insights into the quality of care as seen from the patients' perspective may help healthcare staff better meet patients' needs, wishes, and priorities.

Tailored expectant management in couples with unexplained infertility does not influence their experiences with the quality of fertility care

STUDY QUESTION

Do couples who were eligible for tailored expectant management (TEM) and did not start treatment within 6 months after the fertility work-up, have different experiences with the quality of care than couples that were also eligible for TEM but started treatment right after the fertility work-up?

SUMMARY ANSWER

Tailored expectant management of at least 6 months in couples with unexplained infertility is not associated with the experiences with quality of care or trust in their physician.

WHAT IS KNOWN ALREADY

In couples with unexplained infertility and a good prognosis of natural conception within 1 year, expectant management for 6-12 months does not compromise ongoing birth rates and is equally as effective as starting medically assisted reproduction immediately. Therefore, TEM is recommended by various international clinical guidelines. Implementation of TEM is still not optimal because of existing barriers on both patient and professional level. An important barrier is the hesitance of professionals to counsel their patients for TEM because they fear that patients will be dissatisfied with care. However, if and how adherence to TEM actually affects the couples' experience with care is unknown. Experiences with the quality care can be measured by evaluating the patient-centredness of care and the patients' trust in their physician.

STUDY DESIGN, SIZE, DURATION

This is a retrospective cross-sectional study. A survey with written questionnaires was performed among all couples who participated in the retrospective audit of guideline adherence on TEM in 25 Dutch clinics.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Couples were eligible to participate if they were diagnosed with unexplained infertility and had a good prognosis (>30%) of natural conception within 1 year based on the Hunault prediction model. We used patient's questionnaires to collect data on the couples' experience with the quality of care and possible confounders for their experiences other than having undergone TEM or not. Multilevel regression analyses were performed to investigate case-mix adjusted association of TEM with the patient-centredness of care (PCQ-Infertility) and the patients' trust in their physician (Wake Forest Trust Scale).

MAIN RESULTS AND THE ROLE OF CHANCE

Couples who adhered to TEM experienced the quality of care on the same level as couples who were exposed to early treatment, i.e. started fertility treatment within 6 months after fertility work-up. There were no associations between adherence to TEM and the patient-centredness of care or the patients' trust in their physician.

LIMITATIONS, REASONS FOR CAUTION

Because this study is retrospective, recall bias might occur. Furthermore, we were unable to measure the difference in experience with care over time. Therefore, our results have to be interpreted carefully.

WIDER IMPLICATIONS OF THE FINDINGS

Prospective research on couples undergoing TEM have to be performed to provide more detailed insight in the patients' experiences with the decision making process and subsequently the expectant period. Tackling the barriers surrounding TEM, i.e. better counselling and more patient information material, could further improve patient experiences with the quality of care for couples who are advised TEM.

STUDY FUNDING/COMPETING INTERESTS

Supported by Netherlands Organisation for Health Research and Development (ZonMW). ZonMW had no role in designing the study, data collection, analysis and interpretation of data or writing of the report. Competing interests: none.

TRIAL REGISTRATION NUMBER

www.trialregister.nl NTR3405.

Quality of care in an IVF programme from a patient's perspective: development of a validated instrument

STUDY QUESTION

Is it possible to develop a trustworthy instrument to evaluate the patient's perspective on fertility care and to document fully all methodological steps, including validation?

SUMMARY ANSWER

A validated instrument has been developed for both women and men undergoing assisted reproduction to monitor the quality of care on a regular basis, similar to live birth rates and other effectiveness data. WHAT IS KNOWN ALREADY?: Within fertility care, several instruments have been developed, but many have significant methodological problems and few have been validated. Most instruments focus exclusively on women and no questionnaires have been directed at women and men separately.

STUDY DESIGN, SIZE AND DURATION

The questionnaire specific to IVF treatments (QPP-IVF) is based on the theoretical foundation of the validated general instrument, quality of care from patients perspective (QPP), for both women and men. The QPP-IVF was developed and validated by quantitative methods. A two-centre study ran between September 2011 and May 2012.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In all, 655 women and men participated. The measurements consisted of two kinds of evaluations: the rating of perceived reality of care and the rating of the subjective importance of various aspects of treatment. The questionnaire consisted of 43 items for women and 42 items for men. An exploratory factor analysis was performed for women for all items of subjective importance. Eigenvalue, explained variance and factor loading are given for each factor. Internal consistency of subscales was assessed by Cronbach's alpha, item discriminant validity and percentage scaling success. For external validity, a correlation with fertility quality of life (FertiQoL) was performed and for reliability, a test-retest analysis was carried out. Sensitivity analyses were performed by known-group analyses. All significance tests were two sided and conducted at the 5% significance level.

MAIN RESULTS AND THE ROLE OF CHANCE

The QPP-IVF instrument, divided into four dimensions, seemed a valid and reliable way of measuring the quality of care from a patient's perspective, for both women and men. The item-scaling test confirmed 10 underlying factors, with scaling success in all subscales and Cronbach's alpha >0.70 for women in almost all subscales. It was somewhat lower for men but still acceptable. The external validity was acceptable, with significant correlation between QPP-IVF and FertiQoL. The test-retest analysis confirmed that QPP-IVF was a stable instrument, with intra-class correlation coefficients from 0.74 to 0.89 for women. Sensitivity analyses indicated a sensitive instrument.

LIMITATIONS, REASON FOR CAUTION

The response rate to the questionnaire was 67.5%. Although considered acceptable in questionnaire studies, this response level might introduce a certain risk of selection bias. The questionnaire was developed and validated only in Sweden.

WIDER IMPLICATIONS OF THE FINDINGS

The QPP-IVF may be of use for purposes of quality improvement and national comparisons. Future studies should focus on establishing the QPP-IVF as a valuable instrument for measuring the quality of care outside Sweden.

STUDY FUNDING/COMPETING INTEREST

The study was supported by the LUA/ALF agreement at Sahlgrenska University Hospital, Gothenburg, Sweden and by Hjalmar Svensson's Research Foundation. None of the authors declared any conflict of interests.

Women's views of a fertility awareness and hormonal support approach to subfertility

The aim of this study was to determine the satisfaction among subfertile women of a fertility awareness-based approach, including hormonal therapy to achieve a pregnancy by natural conception. Eighty four women attending a natural fertility service completed a postal questionnaire exploring (1) the acceptability of the sympto-thermal method and (2) the acceptability of using hormone support. Acceptability rates for the fertility charting, clinical service and clinical care were 64.9-91.6%. Acceptability rates were higher in women who did conceive or had experienced past recurrent miscarriages. Taking hormonal luteal support, by any method, was more acceptable for women over 35 years compared to those under 35 years (100% vs. 69.4%, p = 0.014). Vaginal pessaries were the preferred route of administration. The use of a fertility awareness-based method appears to be acceptable amongst subfertile women intending to conceive naturally. Most women using such a method for conception would be open to the use of hormonal support during the fertility cycle or early pregnancy.

Barriers and facilitators for the implementation of an online clinical health community in addition to usual fertility care: a cross-sectional study

BACKGROUND

Online health communities are becoming more popular in health care. Patients and professionals can communicate with one another online, patients can find peer support, and professionals can use it as an additional information channel to their patients. However, the implementation of online health communities into daily practice is challenging. These challenges relate to the fact that patients need to be activated to (1) become a member (ie, subscription) and (2) participate actively within the community before any effect can be expected. Therefore, we aimed at answering 2 research questions: (1) what factors are associated with subscription to an online health community, and (2) which are associated with becoming an active participant within an online health community.

OBJECTIVE

To identify barriers and facilitators as perceived by patients for the implementation of an online health community.

METHODS

We performed a cross-sectional study. Three Dutch fertility clinics (2 IVF-licensed) offered their patients a secure online clinical health community through which clinicians can provide online information and patients can ask questions to the medical team or share experiences and find support from peers. We randomly selected and invited 278 men and women suffering from infertility and attending 1 of the participating clinics. Participants filled out a questionnaire about their background characteristics and current use of the online community. Possible barriers and facilitators were divided into 2 parts: (1) those for subscription to the community, and (2) those for active participation in the community. We performed 2 multivariate logistic regression analyses to calculate determinants for both subscription and active participation.

RESULTS

Subscription appeared to be associated with patients' background characteristics (eg, gender, treatment phase), intervention-related facilitators (odds ratio [OR] 2.45, 95% CI 1.14-5.27), and patient-related barriers (OR 0.20, 95% CI 0.08-0.54), such as not feeling the need for such an online health community. After subscription, determinants for participation consisted of aspects related to participant's age (OR 0.86, 95% CI 0.76-0.97), length of infertility (OR 1.48, 05% CI 1.09-2.02), and to intervention-related facilitators (OR 5.79, 95% CI 2.40-13.98), such as its reliable character and possibility to interact with the medical team and peers.

CONCLUSIONS

Implementing an online health community in addition to usual fertility care should be performed stepwise. At least 2 strategies are needed to increase the proportion of patient subscribers and consequently make them active participants. First, the marketing strategy should contain information tailored to different subgroups of the patient population. Second, for a living online health community, incorporation of interactive elements, as well as frequent news and updates are needed. These results imply that involving patients and their needs into the promotion strategy, community's design, and implementation are crucial.

Predicting dropout in fertility care: a longitudinal study on patient-centredness

STUDY QUESTION

Are clinic factors, including patients' experiences with patient-centred care, associated with dropout in fertility care?

SUMMARY ANSWER

Clinic factors, including patients' experiences with patient-centred care, are not related to dropout.

WHAT IS KNOWN ALREADY

In fertility care, a significant proportion of patients do not achieve pregnancy because they discontinue treatment prematurely. Many studies have tried to identify factors predicting dropout, showing incompatible results. However, these studies mainly focus on factors at the treatment and patient level, while clinic factors have received little attention.

STUDY DESIGN, SIZE, DURATION

This prospective, longitudinal study was nested within a large RCT, which aims to improve the level of patient-centredness of Dutch fertility care. Of the 1620 infertile women who were invited to participate, the baseline measurement of the study (T0) included 693 women who completed a questionnaire about their experiences with patient-centred fertility care. The follow-up of the patients was 1 year (T1).

PARTICIPANTS/MATERIALS, SETTING, METHODS

All included women suffered from infertility and were undergoing treatment in one of the 32 Dutch clinics involved in the trial. Levels of patient-centredness were determined using the Patient-Centredness Questionnaire-Infertility (PCQ-Infertility) at T0. Meanwhile, a professionals' questionnaire was used to gather additional information on characteristics of the clinic (e.g. the number of patients per year or the presence of a fertility nurse). After 1 year, at T1 measurement, patients completed a questionnaire on their current status in fertility care, including their main reason for discontinuation if applicable.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 693 non-pregnant women completed the questionnaire set at T0 and 534 women (77.1%) provided consent for follow-up. At T1 measurement, 434 women (81.3%) completed the questionnaire and 153 of these women (35.2%) continued treatment while 76 women (17.5%) dropped out. Another 175 women (40.3%) had achieved pregnancy and 30 patients (7.9%) were advised to discontinue treatment for medical reasons. Neither levels of patient-centredness nor the additional clinic characteristics differed significantly between dropouts and compliers. However, patients who did not receive assisted reproduction treatment (ART; e.g. underwent intrauterine insemination, IUI) before they dropped out had significantly lower scores on the PCQ-Infertility subscale 'Respect for patients' values' than patients who continued their treatment [odds ratio (OR) 0.57; 95% confidence interval (CI) 0.34-0.95]. Patients who received ART and, subsequently, dropped out had higher scores on the PCQ-Infertility subscale 'Patient involvement' than those receiving non-ART (OR 2.39; 95% CI 1.02-5.59).

LIMITATIONS, REASONS FOR CAUTION

We were not able to follow-up a significant proportion (ca. 19%) of the 1620 women who were invited for T0 measurement, which might have biased our results. We also excluded patients who were still in the diagnostic work-up stage and this might have influenced our results as it is known that patients dropout at this stage. As the PCQ-Infertility was validated in patients who were already undergoing treatment, we decided to focus on this patient group only.

WIDER IMPLICATIONS OF THE FINDINGS

The results of this study provide a better insight into those factors influencing dropout from the perspective of factors in the clinic itself. Although most clinic factors were not related to dropout, clinic factors might be of use when predicting dropout for specific patient groups, such as patients receiving ART and non-ART. Future research should involve an exploration of more specific predictors of dropout at the patient, treatment and clinic levels.

STUDY FUNDING/COMPETING INTERESTS

This work was supported by Merck Serono, the Netherlands. No competing interests declared.

Tackling burden in ART: an integrated approach for medical staff

Discontinuation is a problem in fertility clinics. Many couples discontinue assisted reproductive technologies (ART) without achieving a live birth for reasons other than poor prognosis or the cost of treatment. Discontinuation has been attributed to the burden of treatment. The causes of burden can be broadly classified according to whether they originate in the patient, clinic or treatment. Interventions to alleviate these burdens include provision of comprehensive educational material, screening to identify highly distressed patients, provision of tailored coping tools and improvements in the clinic environment and medical interventions. Practical interventions to reduce the different causes of burden in ART exist, but further development and evaluation of the efficacy of these interventions requires more precise definition of terms and theory. In this paper, we propose a general integrated approach to cover different perspectives in dealing with burden in ART clinics. We firstly describe the integrated approach and present common sources of burden. We then describe interventions that could help reduce the burden in ART. Our paper is aimed at fertility clinic staff because of their day-to-day involvement with patients. However, this discussion should also be relevant to companies that develop treatments and to psychosocial experts. Reducing the burden of treatment should lead to improved outcomes, namely better quality of life during treatment and lower discontinuation rates.

Pregnancy and adoption among infertile women following ovulation induction and intrauterine insemination

Using a retrospective cohort study, 214 clinically diagnosed infertile women who underwent ovulation induction and intrauterine insemination between 1991 and 1994 at a hospital-based centre of reproductive medicine, were followed up 5 years after treatment to assess their overall health, pregnancy and adoption status. Multivariate logistic regression analysis was used to estimate odds ratios and 95% confidence intervals for these outcomes, adjusted for age, education, infertility diagnosis, infertility status, parity, number of prior intrauterine insemination cycles, pregnancy following intrauterine insemination treatment, and undergoing other assisted reproductive procedures. Significant increased likelihood of pregnancy was observed for younger women, for women with secondary versus primary infertility, and for women who underwent other assisted reproductive procedures versus those who did not. Significant decreased likelihood of adoption was observed for women with a lower versus a higher educational level, for women with secondary versus primary infertility, and for parous versus nulliparous women. Although the analyses were mostly based on self-reported data, infertile women may adopt or conceive with or without assisted reproductive techniques resulting in minimal change in overall health, and eventually adjust to infertility treatment and its aftermath.

Testicular biopsy before ART: the patients' perspective on the quality of care

BACKGROUND

So far, research on the patients' perspective on fertility care has mainly focused on women. Our primary aim was to explore what is important to men with respect to care related to testicular sperm extraction (TESE) and to identify strengths and weaknesses of that care.

METHODS

This was a mixed-method study including phenomenology on interviews with 17 'interview participants' (a purposive sample with diversification for the TESE result) who received a TESE treatment at a tertiary university clinic. Strengths and weaknesses of our TESE-related quality of care were identified. Additionally, a telephone questionnaire was answered by 15 'rating participants' not willing to be interviewed and the questionnaire was analyzed quantitatively.

RESULTS

Interview participants wanted more than effective treatment and attached importance to the attitude of fertility clinic staff, information, time flow, personalized care, 'all that is necessary', coaching, a homely atmosphere, continuity, privacy and separate accommodation. The satisfaction of rating participants (independent of the TESE result) was problematic for 'overall experience', 'physician at the day clinic' and 'gynecologist at discussion of the result'. The attitude of fertility clinic staff and information were the most obvious strengths of our TESE-related care. Weaknesses were lack of practical information on post-surgical recovery and waiting times in the waiting room.

CONCLUSIONS

TESE patients focus not only on clinical effectiveness but also on patient-centeredness of care, and this has led to organizational changes and a new patient information brochure in our center. Qualitative research is useful to examine, understand and improve the patient-centeredness of care.

Organizational determinants of patient-centered fertility care: a multilevel analysis

OBJECTIVE

To identify organizational determinants of positive patient experiences with fertility care, with the goal of improving patient centeredness of care.

DESIGN

Cross-sectional survey.

SETTING

One large university clinic and 12 medium-sized fertility clinics in the Netherlands.

PATIENT(S)

Three hundred and sixty-nine couples receiving medically assisted reproduction in one of the participating clinics between March and May 2008.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Organizational determinants of patients' experiences with patient centeredness in fertility care.

RESULT(S)

Of the patients during the relevant period, 78% of the women and 76% of their partners participated in the study. Infertile couples who have a lead physician, have access to an electronic personal health record, or see trained fertility nurses have more positive experiences with aspects of patient-centered care, like continuity of care and partner involvement. Moreover, receiving a treatment other than in vitro fertilization was negatively associated with the perceived patient centeredness of care. The identified determinants explained 5.1% to 22.4% of the total variance.

CONCLUSION(S)

This study provides organizational determinants of patients' experiences with fertility care on numerous facets of patient centeredness. These organizational determinants can be used as valuable tools to enable clinics to provide a more positive patient experience.

The patients' perspective on fertility care: a systematic review

BACKGROUND

Patient-centered reproductive medicine (PCRM) is important for quality of care, and this is increasingly being recognized. However, its scientific basis is unclear. The main research questions addressed in this review are: 'How has the patients' perspective on fertility care been examined (method and quality)?' and 'What is the perspective of patients in developed countries on fertility care?'.

METHODS

A systematic search of electronic databases was conducted and inclusion criteria with respect to eligibility and quality were applied. The methodology of the studies was critically appraised; the findings of the studies were synthesized and organized according to: patients' value clarification and assessment of service quality and dimensions of patient-centeredness. Additionally data on patient preferences and determinants of patients' perspective on care were collected.

RESULTS

In 51 selected studies, patients' perspective on fertility care was examined with (few or many item) questionnaires and/or qualitative interviews. Significant methodological problems were observed. Fertility patients attached importance to seven out of eight dimensions of patient-centeredness (Picker institute) and two new dimensions 'fertility clinic staff' and 'skills' were developed. Overall, fertility patients want to be treated like human beings with a need for: medical skills, respect, coordination, accessibility, information, comfort, support, partner involvement and a good attitude of and relationship with fertility clinic staff. Patients' preferences between procedures and demographic, medical and psychological determinants of their perspective were defined.

CONCLUSIONS

Fertility patients have 'human needs' besides their need for medical care. Evidence on PCRM is available but significant methodological limitations call for the development and validation of a European questionnaire.

Weaknesses, strengths and needs in fertility care according to patients

BACKGROUND

The patients' role in assessing health care quality is increasingly recognized. Measuring patients' specific experiences and needs generates concrete information for care improvement, whereas satisfaction surveys only give an overoptimistic, undifferentiating picture. Therefore, this study aimed to investigate possible weaknesses, strengths and needs in fertility care by measuring patients' specific experiences.

METHODS

Mixed (qualitative and quantitative) methods were used to identify weaknesses, strengths and needs in fertility care. Four focus groups with 21 infertile patients were used for documenting care aspects relevant to patients. The fully transcribed qualitative results were analysed and converted into a 124-item questionnaire, to investigate whether these aspects were regarded as weaknesses, strengths or needs in fertility care. The questionnaire was distributed to 369 eligible couples attending 13 Dutch fertility clinics. Descriptive statistics were used to determine the quantity of the weaknesses, strengths and needs.

RESULTS

Overall, 286 women (78%) and 280 men (76%) completed the questionnaire. Patients experienced many weaknesses in fertility care, mostly regarding emotional support and continuity of care. Respect and autonomy and partner involvement were considered strengths in current care. Furthermore, women expressed their need for more doctors' continuity during their treatment, and couples strongly desired to have free access to their own medical record. The questionnaire's internal consistency and construct validity were sufficient.

CONCLUSIONS

Infertile couples experience strengths, but also many weaknesses and needs in current fertility care. Lack of patient centredness seems to be a major cause herein. Using mixed methods is a sensitive means for identifying these weaknesses and needs.