Deciding how many embryos to transfer: ongoing challenges and dilemmas

Trans-abdominal fetal reduction in higher order multiple pregnancies: a pioneer cohort retrospective study in Nepal

Objective

To share the initial experience of trans-abdominal multifetal pregnancy reduction (MFPR) in Nepal.

Method

The procedure was performed in 108 patients in a private hospital over a period of 3 years. Under ultrasound guidance, intracardiac injection of 0.2-3.0 ml of 15% w/v (2 mEq/ml) potassium chloride (KCl) was administered via trans-abdominal route.

Results

A total of 108 fetal reduction procedures were carried out at the seventh to fifteenth weeks of gestation, a maximum of 44 (40.7%) of which were done at the ninth to tenth weeks of gestation. A total of 123 fetuses were reduced. Out of total 108 multifetal pregnancies, 96 (88.8%) were due to in-vitro fertilization (IVF). Eighty-five pregnancies (78.7%) underwent reduction from triplet to twin. The second-time reduction was needed in five cases. Two attempts (in the same sitting) were required in three cases. The inadvertent demise of the second fetus was noted in three cases of dichorionic tri-amniotic triplet pregnancy.

Conclusion

Ultrasound-guided trans-abdominal fetal reduction performed between the seventh and twelfth weeks of gestation is safe and effective.

The evolving roles of extracellular vesicles in embryo-maternal communication

Mammalian reproduction relies on precise maternal-fetal communication, wherein immune modifications foster tolerance toward the semi-allogeneic embryo. Extracellular vesicles (EVs), including exosomes and microvesicles, have emerged as crucial mediators, transporting molecules like microRNAs securely. EVs influence various reproductive stages, from gamete maturation to implantation, and impact pathologies like pregnancy loss. In the embryo-maternal dialogue, EVs notably affect oviductal interactions, gene expression, and the embryo-endometrial interface, crucial for successful implantation. Key queries persist about EV uptake, cargo delivery, and the specific biomolecules driving communication. Their potential in diagnostics, therapeutics, and understanding environmental impacts on fertility signals an exciting future, reliant on collaborative efforts for transformative strides in reproductive health.

Bearing Witness to Joy and Sorrow: Narrative Medicine and Reproductive Endocrinologist and Infertility (REI) Providers' Journeys in Infertility Treatment

This study examines providers' perceptions of provider-patient communication in reproductive endocrinology and infertility (REI) practices. Grounded in narrative medicine, we interviewed six REI providers about their experiences providing fertility care. REI providers crafted a narrative of bearing witness by (1) situating personal and professional self in REI narratives, (2) sharing news as important medical moments, and (3) cultivating affiliation between provider and patient. These findings offer insight into the power of narrative medicine in fertility care, the role of emplotment in narrative sense-making, and the emotional labor associated with information delivery in REI treatments. We offer several recommendations for how patients and providers can improve communication experiences in REI.

Comparing ART outcomes in women with endometriosis after GnRH agonist versus GnRH antagonist ovarian stimulation: a systematic review

Background

Endometriosis is an oestrogen-dependent disease that can cause subfertility in women who may require assisted reproductive technology (ART) to achieve their pregnancy goals.

Objectives

The aim of this study was to compare ART outcomes in women with endometriosis following the long GnRH-agonist controlled ovarian stimulation (COS) protocol with those taking the GnRH-antagonist COS protocol.

Data Sources and Methods

MEDLINE, Embase and Web of Science were systematically searched in June 2022. Randomized controlled trials (RCTs) and observational studies comparing the long GnRH-agonist COS protocol and the GnRH-antagonist COS protocol in women with all stages/subtypes of endometriosis were included. Data were synthesized into comprehensive tables for systematic review. The Scottish Intercollegiate Guidelines Network (SIGN) checklists were used for the risk of bias assessment of non-randomized studies and randomized studies, and all the included studies were deemed to have acceptable quality.

Main Results

Eight studies (one RCT and seven observational) with 2695 patients (2761 cycles) were included. Most studies generally reported non-significant differences in clinical pregnancy or live birth rates regardless of the COS protocol used. However, the GnRH-agonist protocol may yield a higher total number of oocytes retrieved, especially mature oocytes. Conversely, the GnRH-antagonist protocol required a shorter COS duration and lower gonadotrophin dose. Adverse outcomes, such as rates of cycle cancellation and miscarriage, were similar between both COS protocols.

Conclusion

Both the long GnRH-agonist and GnRH-antagonist COS protocols generally yield similar pregnancy outcomes. However, the long GnRH-agonist protocol may be associated with a higher cumulative pregnancy rate due to the higher number of retrieved oocytes available for cryopreservation. The underlying mechanisms of the two COS protocols on the female reproductive tract remain unclear. Clinicians should consider treatment costs, stage/subtype of endometriosis and pregnancy goals of their patients when selecting a GnRH analogue for COS. A well-powered RCT is needed to minimize the risk of bias and compare the risk for ovarian hyperstimulation syndrome.

Registration

This review was prospectively registered at PROSPERO under Registration No. CRD42022327604.

Obstetric Outcomes and Successful Reduction of Twin Pregnancies Achieved by In Vitro Fertilization

The use of in vitro fertilization methods around the world is constantly increasing. In some developed countries, up to 5% of newborns are as a result of pregnancies after IVF procedures. In vitro fertilization as one of the main and widespread methods for treatment of infertility is the main reason for the high frequency of multiple pregnancies, which, in many countries, is still too high. Most of the multiple pregnancies are in fact twin pregnancies. Twin pregnancies, regardless of how they are achieved, are associated with large number of complications compared with singleton ones. More often these pregnancies can lead to maternal complications and adverse pregnancy outcomes. Maternal complications include development of preeclampsia, gestational diabetes, placenta previa, placental abruption, premature rupture of membranes, antepartum and postpartum hemorrhage, and delivery by cesarean sections. Adverse pregnancy outcomes mostly include preterm birth (PTB), low birth weight (LBW), small for gestational age newborn (SGA), intrauterine growth restriction (IUGR), neonatal respiratory distress syndrome (RDS), and admission to neonatal intensive care unit (NICU). A number of studies have found differences in the course of twin pregnancies according to their mode of occurrence – spontaneous or after IVF. Some of them have found that twin pregnancies after IVF are associated with poorer obstetric and perinatal outcomes, others do not find such a difference, and there are even studies that find a better outcome in IVF twin pregnancies. Twin pregnancy is a common occurrence after IVF procedure, because multiple-embryo transfer is commonly regarded as an effective strategy to improve the likelihood of a successful pregnancy. Understanding the risks of these pregnancies should be a strong motive for the transfer of fewer embryos during IVF procedures. The most effective way to do this is to transfer a single-embryo into the uterus in cases, where this is justified and the chances of getting pregnant are high. An important element in achieving this goal is the use of methods for vitrification of embryos, which leads to a sufficiently high rate of clinical pregnancies after freezing of embryos obtained by IVF and their subsequent transfer after thawing in case of failure of fresh ET.

Protective placental inflammatory and oxidative stress responses are attenuated in the context of twin pregnancy and chorioamnionitis in assisted reproduction

PURPOSE

Assisted reproduction technologies (ART) are associated with increased risks of pregnancy complications and obstetric interventions. Here, we aimed to determine if ART affects placental inflammation and oxidative stress as a mechanism for unfavorable pregnancy outcomes.

METHODS

The levels of six cytokines (IFN-γ, IL-1β, IL-6, IL-8, IL-10, TNFα) were measured using multiplex ELISA. The activity of four antioxidant enzymes (glutathione S-transferase (GST), glutathione peroxidase (GPx), glutathione reductase, superoxide dismutase) and levels of two antioxidants (GSH, vitamin E) were measured using commercial/in-house assays. Markers were compared between ART and unassisted pregnancies, and then groups were stratified using ICD9/10 codes to determine differences in specific clinical contexts.

RESULTS

In unassisted twin pregnancies, there was a trend of decreased cytokine levels (IL-1β, IL-6, IL-8, TNFα, p < 0.05), but cytokines in ART twins were the same or higher. Additionally, GST and GPx activities were lower in unassisted twins, and vitamin E levels were higher in ART twins (p < 0.05). In pregnancies complicated by chorioamnionitis, there was a trend of increased cytokine levels in unassisted pregnancies (IL-1β, IL-6, and IL-8, p < 0.05). No increase was observed in ART, and IFN-γ and TNFα were decreased (p < 0.05). Placental GST and GPx activities were higher in unassisted pregnancies with chorioamnionitis compared to ART (p < 0.05).

CONCLUSION

Attenuation of protective placental inflammatory and oxidative stress responses may play a role in the underlying pathogenesis of negative birth outcomes in ART, expanding our understanding of adverse pregnancy outcomes when ART is used to conceive.

Pregnancy Outcomes Following the First Frozen Blastocyst Transfer Among Women Aged Less Than 35 Years Old: A Retrospective Cohort Study

Background: Many guidelines have been issued regarding the number of embryos to be transferred after in vitro fertilization (IVF), but patients and clinicians may be reluctant to accept or offer a single embryo transfer due to the expected lower chance of pregnancy or live birth. This study was aimed to provide additional information on cycle outcome according to the number and quality of thawed transferred blastocysts.

Methods: A retrospective cohort study was designed to collect the data of 505 patients who performed the first frozen blastocysts transfer at Tam Anh General Hospital from June 2018 to September 2019. One good-quality embryo was transferred for 121 patients (Group 1), two good for 214 patients (Group 2), one good and one poor for 112 patients (Group 3), one good and two poor for 25 patients (Group 4), and one or two poor for 33 patients (Group 5).

Results: The pregnancy rate was 71.9%, 74.8%, 69.4%, 84.0%, and 39.4% in Group 1–5, respectively. The multiple pregnancy rate was 36.9%, 16.9%, and 32.0% in Groups 2–4, respectively, higher than Group 1 (4.9%). The live birth rate was 55.6%, 50.9%, and 60.0% in Group 2–4, respectively, but not significantly different from the Group 1 (47.9%).

Conclusions: Transferring an additional good or poor embryo, along with a good embryo, does not increase the live birth rate while the incidence of multiple pregnancies rises significantly.

First-time mothers' experiences of foetal reduction in pregnancy following assisted reproductive technology treatment in Taiwan: a qualitative study

BACKGROUND

Foetal reduction-removal of one or more foetuses to reduce the number of foetuses in multiple conceptions-is a procedure used for improving pregnancy outcomes following assisted reproductive technology (ART) treatment. While there is a recognition of the importance of understanding the experiences of women who undergo foetal reduction to offer appropriate help and support, studies that provide relevant insights are sparse. Our aim was to gain an in-depth understanding about first-time mothers' experiences of foetal reduction following ART treatment in Taiwan.

METHODS

We adopted a qualitative design based on a phenomenological approach for this study. In-depth semi-structured interviews were conducted with seven first-time mothers who underwent foetal reduction following ART treatment at a fertility centre in Taipei, Taiwan. All interviews were recorded, transcribed and analysed using the Colaizzi strategy.

RESULTS

The views and experiences relating to foetal reduction reflected five key themes: hesitation, ambivalence and distress; the guilt of knowingly terminating a life; rituals and ceremonies to ease the sense of guilt; persuading oneself to consider the 'big picture'; and wishing for a reunion in next pregnancy. Mothers often regretted that they took clinical advice to implant multiple embryos and then having had to resort to foetal reduction. There was a sense of hesitation, ambivalence and distress reflected in the views from all participants. They believed that they ended the fetuses' lives knowingly and expressed strong feelings of guilt. Mothers often tried to persuade themselves to look at foetal reduction within the 'big picture' of the overall pregnancy outcome. Losing their unborn babies was as an unforgettable incident for most mothers, and they wished for a reunion with the lost baby in the next pregnancy.

CONCLUSION

Findings indicate the need for ART providers to undertake a more sensitive approach that involves detailed discussions with women and their families to tailor the embryo transfer processes to suit individual needs. Women who undergo foetal reduction should be provided with tailored interventions towards enhancing their coping strategies before and after foetal reduction taking into account the cultural and religious context.

In Vitro Fertilization: A Pastoral Taboo?

Scholars have shown how the moral limitations and caveats that many religions pose against new assisted reproductive technologies have hindered women's medical help-seeking. In the context of reproductive medicine, Catholics, compared to other religious groups (Evans and Hudson 2007), are more likely to disapprove in vitro fertilization (IVF). This article explores, through a qualitative empirical study, the absence of dialogue between Catholic congregants and their priests about IVF. On the one hand, parishioners primarily spoke about infertility issues in a very general manner, but would barely enter into any details. On the other hand, members of the clergy wouldn't mention IVF's prohibition unless they were specifically questioned on that matter. This article proposes explanations for this silence.

International Committee for Monitoring Assisted Reproductive Technologies (ICMART): world report on assisted reproductive technologies, 2013

OBJECTIVE

To report the utilization, effectiveness, and safety of practices in assisted reproductive technology (ART) globally in 2013 and assess global trends over time.

DESIGN

Retrospective, cross-sectional survey on the utilization, effectiveness, and safety of ART procedures performed globally during 2013.

SETTING

Seventy-five countries and 2,639 ART clinics.

PATIENT(S)

Women and men undergoing ART procedures.

INTERVENTION(S)

All ART.

MAIN OUTCOME MEASURE(S)

The ART cycles and outcomes on country-by-country, regional, and global levels. Aggregate country data were processed and analyzed based on methods developed by the International Committee for Monitoring Assisted Reproductive Technology (ICMART).

RESULT(S)

A total of 1,858,500 ART cycles were conducted for the treatment year 2013 across 2,639 clinics in 75 participating countries with a global participation rate of 73.6%. Reported and estimated data suggest 1,160,474 embryo transfers (ETs) were performed resulting in >344,317 babies. From 2012 to 2013, the number of reported aspiration and frozen ET cycles increased by 3% and 16.4%, respectively. The proportion of women aged >40 years undergoing nondonor ART increased from 25.2% in 2012 to 26.3% in 2013. As a percentage of nondonor aspiration cycles, intracytoplasmic sperm injection (ICSI) was similar to results for 2012. The in vitro fertilization (IVF)/ICSI combined delivery rates per fresh aspiration and frozen ET cycles were 24.2% and 22.8%, respectively. In fresh nondonor cycles, single ET increased from 33.7% in 2012 to 36.5% in 2013, whereas the average number of transferred embryos was 1.81-again with wide country variation. The rate of twin deliveries after fresh nondonor transfers was 17.9%; the triplet rate was 0.7%. In frozen ET cycles performed in 2013, single ET was used in 57.6%, with an average of 1.49 embryos transferred and twin and triplet rates of 10.8% and 0.4%, respectively. The cumulative delivery rate per aspiration was 30.4%, similar to that in 2012. Perinatal mortality rate per 1,000 births was 22.2% after fresh IVF/ICSI and 16.8% after frozen ET. The data presented depended on the quality and completeness of the data submitted by individual countries. This report covers approximately two-thirds of world ART activity. Continued efforts to improve the quality and consistency of reporting ART data by registries are still needed.

CONCLUSION(S)

Reported ART cycles, effectiveness, and safety increased between 2012 and 2013 with adoption of a better method for estimating unreported cycles.

The Effect of Additional Embryo Transfer on the Pregnancy Rate in Young Women Receiving in vitro Fertilization: A Natural Experiment Study

Purpose

To assess the impact of additional embryo transfer (ET) on pregnancy in young women, we used a natural-experiment approach.

Patients and Methods

The design was based on the national policy of South Korea limiting the number of embryos transferred in vitro fertilization (IVF):≦2 embryos on day 2–4 or one on day 5–6 for patients aged <35, with one extra embryo allowed for patients aged ≥35. Using the data from 1909 ET cycles of 1287 women aged ≥34 and ≤35, we calculated adjusted risk ratios (RRs) for pregnancy.

Results

Half of cycles were undertaken by women aged 35, and additional ET was performed in 68.7% of them. Intrauterine pregnancy (45.2% vs 51.3%) and multiple gestation (30.5% vs 6.9%) were more common in women aged 35 than in those aged 34. The RR for intrauterine pregnancy was 1.34 (95% confidence interval: 1.12–1.59) when comparing double ET to single ET in frozen day 5–6 cycles.

Conclusion

We observed no evidence of a higher probability of pregnancy with additional ET in fresh or frozen day 3–4 ET, or in fresh day 5–6 ET of women aged 35. Additional ET may not increase the successful pregnancy rate in the 35-year-old group, unless it is a frozen day 5–6 ET cycle.

Temporal trends in preterm birth phenotypes by plurality: Black-White disparity over half a century

OBJECTIVE

To examine trends in rates of preterm birth by race and plurality; to evaluate the association between race, plurality, and phenotypes of preterm birth.

STUDY DESIGN

Temporal trends analyses for preterm birth by race and plurality were performed for the years 1971-2018. Adjusted logistic regression models were utilized to evaluate the association between race, plurality, and phenotypes of preterm birth.

RESULTS

We observed that 1105,266 (0.7%), 1901,604 (1.2%), and 14,769,746 (9.3%) births belonged to extreme preterm, very preterm, and moderate-to-late preterm categories, respectively. We also observed that the risk of extreme preterm (RR: 2.69, 95% CI: 2.642-2.75) was highest for Black mothers as compared to White mothers.

CONCLUSION

Over the study period, preterm births disproportionately impacted Black mothers as well as pregnancies of higher plurality. With the persistence of racial disparities and growing trend of delayed childbearing and multiple pregnancies, targeted intervention is necessitated toward these vulnerable subgroups.

Dydrogesterone as an oral alternative to vaginal progesterone for IVF luteal phase support: A systematic review and individual participant data meta-analysis

The aim of this systematic review and meta-analysis was to conduct a comprehensive assessment of the evidence on the efficacy and safety of oral dydrogesterone versus micronized vaginal progesterone (MVP) for luteal phase support. Embase and MEDLINE were searched for studies that evaluated the effect of luteal phase support with daily administration of oral dydrogesterone (20 to 40 mg) versus MVP capsules (600 to 800 mg) or gel (90 mg) on pregnancy or live birth rates in women undergoing fresh-cycle IVF (protocol registered at PROSPERO [CRD42018105949]). Individual participant data (IPD) were extracted for the primary analysis where available and aggregate data were extracted for the secondary analysis. Nine studies were eligible for inclusion; two studies had suitable IPD (full analysis sample: n = 1957). In the meta-analysis of IPD, oral dydrogesterone was associated with a significantly higher chance of ongoing pregnancy at 12 weeks of gestation (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.08 to 1.61; P = 0.0075) and live birth (OR, 1.28; 95% CI, 1.04 to 1.57; P = 0.0214) compared to MVP. A meta-analysis combining IPD and aggregate data for all nine studies also demonstrated a statistically significant difference between oral dydrogesterone and MVP (pregnancy: OR, 1.16; 95% CI, 1.01 to 1.34; P = 0.04; live birth: OR, 1.19; 95% CI, 1.03 to 1.38; P = 0.02). Safety parameters were similar between the two groups. Collectively, this study indicates that a higher pregnancy rate and live birth rate may be obtained in women receiving oral dydrogesterone versus MVP for luteal phase support.

Morphokinetic parameters as auxiliary criteria for selection of blastocysts cultivated in a time-lapse monitoring system

Objective:

To describe embryonic profile up to blastocyst stage in a time-lapse system.

Methods:

A retrospective, longitudinal, analytical study of patients submitted to in vitro fertilization. The embryos were grouped according to the degree of expansion, internal cell mass and trophectoderm classification, the morphokinetic parameters were associated with the time periods stated in each evolution phase.

Results:

The appearance of a second polar corpuscle (CPap) occurred earlier in the embryos classified as excellent (2.99h; p<0.05), in relation to the embryos classified as good (3.40h), average (3.48h) and poor (3.55h). The embryos classified as excellent took less time for the pronuclei to disappear (PNbd) (21.80h; p<0.05), when compared to the good embryos (22.96h), the average (23.21h) and the poor (23.47h). As for the morphokinetic parameter, the end of the two-cell division (T2) occurred first in the excellent blastocysts (24.38h; p<0.05), when compared to the other groups: good (25.57h), average (25.53h) and poor (25.78h). With respect to synchronization with the division of three to four cells (S2), the poor embryos presented longer times for such division to occur (3.67h; p<0.05). When compared to the embryos from the groups excellent (1.97h), good (2.70h) and average (2.09h). At the time point of the blastocoel formation (TB), the excellent embryos (104.04h) did not differ from the good embryos (104.10h). However, when compared to average (107.27h) and poor (106.86h) embryos, there was statistical significance (p<0.05).

Conclusions:

Embryos of better quality had a shorter time in some morphokinetic parameters when compared to the other groups, thus increasing the possibilities to establish new parameters for the classification and selection of embryos.

Why are multiple pregnancy rates and single embryo transfer rates so different globally, and what do we do about it?

In the early years of in vitro fertilization, overall pregnancy rates were low, and it was considered necessary to transfer more than one embryo to increase the chances of pregnancy. It was not until advances in assisted reproductive technologies resulting in increased pregnancy rates that the concept of transferring just one embryo was considered possible. A consequence of improvements in implantation rates was also an increase in multiple pregnancies when more than one embryo was transferred. Although some countries have reduced the number of embryos transferred, international data show that in many parts of the world high twin and higher order multiple pregnancy rates still exist. Even in developed countries these problems persist depending on clinical practice, funding of health services, and patient demands. Perinatal and other outcomes are significantly worse with twins compared with singleton pregnancies and there is an urgent need to reduce multiple pregnancy rates to at least 10%. This has been achieved in several countries and clinics by introducing single embryo transfer but there are many barriers to the introduction of this technique in most clinics worldwide. We discuss the background to the high multiple rate in assisted reproduction and the factors that contribute to its persistence even in excellent clinics and in high-quality health services. Practices that may promote single embryo transfer are discussed.

Retrospective Analysis of Obstetric Intensive Care Unit Admissions Reveals Differences in Etiology for Admission Based on Mode of Conception

BACKGROUND

The use of in vitro fertilization is increasing. The incidence of adverse outcomes is greater for women who undergo in vitro fertilization, potentially leading to intensive care unit admission. This study aimed to assess the etiology and course of intensive care unit admission in women who underwent in vitro fertilization compared to those who did not, with specific focus on intensive care unit admission due to postpartum hemorrhage.

METHODS

In this retrospective study, medical records of patients admitted to the intensive care unit during pregnancy or the peripartum period at 2 medical centers (2005-2016 at Mount Sinai Hospital, New York, NY, and 2005-2013 at Shaare Zedek Medical Center, Jerusalem, Israel) were analyzed. Demographic, past medical and obstetric history, and details regarding delivery and intensive care unit stay were collected, as was information regarding mode of conception (in vitro fertilization versus non-in vitro fertilization) for the current pregnancy. The primary outcome measure was difference in etiology of intensive care unit admission between in vitro fertilization and non-in vitro fertilization groups. Secondary outcome measures included differences in prepregnancy characteristics, incidence, severity, and management of postpartum hemorrhage, as well as incidence of other clinical major morbidity events and delivery-related complications. Multivariable logistic regression was performed to study the relationship between in vitro fertilization and the odds of having been admitted to the intensive care unit due to hemorrhage.

RESULTS

During the study period, there were nearly 192,000 deliveries, with 428 pregnant and peripartum women admitted to the intensive care unit. Of the 409 cases analyzed, 60 had conceived following in vitro fertilization and 349 had conceived without in vitro fertilization. The non-in vitro fertilization group was more likely to have multiple medical comorbidities, and the in vitro fertilization group was more likely to have multiple gestations. The groups also differed in etiology of intensive care unit admission; more women in the in vitro fertilization group were admitted due to a pregnancy-related complication. Intensive care unit admission for postpartum hemorrhage was more frequent in the in vitro fertilization group (60.0% vs 43.1%, P = .014), with a 2-fold increase in the incidence of hemorrhagic shock. Logistic regression analysis revealed a 2-fold increase in the odds that intensive care unit admission was due to hemorrhage in women undergoing in vitro fertilization, a finding that was not statistically significant when multiple gestation was added to the model.

CONCLUSIONS

Among patients admitted to the intensive care unit, patients with different modes of conception had dissimilar etiologies for intensive care unit admission with intensive care unit admission due to hemorrhage greater in those with in vitro fertilization. Higher rates of multiple gestation pregnancies may explain this difference. Differences in pregnancies conceived via in vitro fertilization versus without in vitro fertilization may affect the obstetric intensive care unit case mix.

Impediments to communication and relationships between infertility care providers and patients

BACKGROUND

Infertility patients generally see provider-patient communication and relationships as important, but as often insufficient, raising critical questions regarding why these gaps persist, and how they might best be addressed.

METHODS

Semi-structured interviews of approximately one hour each were conducted with 37 ART providers and patients (17 physicians, 10 other health providers, and 10 patients) and were thematically analyzed.

RESULTS

Patients see clinicians' interactions as ranging widely from good to bad, related to several specific barriers and factors. Patients and providers may differ in their physical and emotional experiences, expectations concerning treatment outcomes and uncertainties, and time frames and finances, generating dynamic processes and tensions. Characteristics of particular providers, clinics and patients can also vary. Infertility patients tend to find only one outcome acceptable - a "take home baby" - rather than partial success, as is the case with many other diseases. Yet most IVF cycles fail. Many patients must pay considerable out-of-pocket expenses for infertility treatment, exacerbating disappointments and frustrations. Providers often work in competitive, entrepreneurial markets, and "hype" their potential success. After treatment failures, providers may feel guilty and withdraw from patients. Yet these behaviors can antagonize patients more than physicians realize, aggravating patient stresses. Several providers described how they understood patients' needs and perceptions more fully only after becoming infertility patients themselves. Interactions with not only physicians, but other providers (e.g., nurses and staff) can play key roles. Patients may be willing to understand these impediments, but providers often communicate these obstacles and reasons poorly or not at all, furthering tensions.

CONCLUSIONS

These data, the first to examine several critical aspects of challenges that infertility providers and patients face in communication and relationships, suggest that several key dynamic processes and factors may be involved, and need to be addressed. While prior research has shown that infertility patients value, but often feel disappointed in relationships with clinicians, the present data highlight several specific impediments, and thus have critical implications for future practice, research, guidelines and education.

Physicians and patients' motivations to perform elective single or double-embryo transfers: A nationwide survey

OBJECTIVES

To evaluate motivations to perform an elective single embryo transfer (e-SET).

METHODS

Cross-sectional surveys to reproductive medicine specialists and to infertile patients undergoing assisted reproductive treatments.

RESULTS

In the physician's survey (n = 278), we found that the main reasons for not offering e-SET were the physicians' belief that patients prefer optimizing the pregnancy rates regardless of the potential complications (57.1%). Regarding the decision making process, 76.7% of physicians thought that patients and doctors should make these decisions together and 93.3% would like to have a more formal decision-aid to help with counseling. In the patients' survey (n = 100), 21.3% chose e-SET, while 33% mentioned that complications associated to multiple pregnancies were insufficiently discussed. Among those patients, none chose to have e-SET, while 30% of those who had a full discussion selected e-SET (p = 0.05).

CONCLUSIONS

Most physicians did not offer e-SET based on potential patients' negative feelings. Also, almost 30% take important decisions without the patient's participation. Patients that discussed more thoroughly this topic, more frequently selected e-SET. Almost all the physicians surveyed agreed that decision-aids could help in this important shared-decision process.

PRACTICE IMPLICATIONS

Decision aids about e-SET vs DET are needed to help patients in the decision making process.

Gatekeepers for infertility treatment? Views of ART providers concerning referrals by non-ART providers

Many patients who might benefit from treatment using assisted reproductive technology (ART) do not receive it, raising critical questions of why, and how best to overcome existing barriers. In-depth interviews of approximately 1 h each were conducted with 27 ART providers (17 physicians and 10 other healthcare providers). These interviewees suggest that non-ART providers may serve as gatekeepers in a complex system, involving not only individual-level, but also dyadic and institutional, processes and factors related to provider-patient relationships. Differences emerge concerning 'who' refers patients for ART (e.g. what types of provider), 'how' (amount, type and specificity of information offered), 'when' (delayed or not) and 'why or why not', and how patients respond to referrals, once made. At least seven types of clinician (general practitioners, obstetricians/gynaecologists, paediatricians, geneticists, psychologists and oncologists) may refer patients. Barriers to referral include indistinct boundaries between specialties and provider discomfort discussing reproduction and sex. These data, the first to explore dynamic factors and processes related to provider-patient relationships and interactions in referrals of patients for ART, suggest several key issues (e.g. non-ART providers' roles as gatekeepers), and implications for future education, practice, guidelines and research, highlighting a research agenda, and the need for targeted education for different groups of clinicians.

How Infertility Patients and Providers View and Confront Religious and Spiritual Issues

Questions arise concerning whether and how religion affects infertility treatment decisions. Thirty-seven infertility providers and patients were interviewed. Patients confront religious, spiritual, and metaphysical issues coping with treatment failures and religious opposition from clergy and others. Religion can provide meaning and support, but poses questions and objections that patients may try to avoid or negotiate-e.g., concealing treatment or changing clergy. Differences exist within and between religions. Whether and how much providers discuss these issues with patients varies. These data, the first to examine several key aspects of how infertility providers and patients confront religious/spiritual issues, have important implications for practice, research, guidelines, and education.

Infertility providers' and patients' views and experiences concerning doctor shopping in the USA

Many questions arise concerning how infertility patients decide whether, how much and why or why not to consult more than one doctor and change physicians. To explore this issue, a total of 37 US in vitro fertilization (IVF) providers and patients were interviewed in-depth. Many infertility patients feel disappointed with infertility providers, especially after treatment failure, and then struggle to evaluate and weigh relative 'bedside manner' against technical skills, finances and hope, facing dilemmas of which doctor to choose, whether and how much, to 'shop around', how to do so, and whether and how much to give doctors 'second chances'. Complex, dynamic processes can ensue: shopping for initial or subsequent physicians and consulting and/or changing doctors multiple times, based on differing treatment approaches. Patients may alter perceptions of physicians over time. Providers are often busy and have difficulty addressing patients' emotional stresses; and may provide providing 'false hope', and/or criticize colleagues' approaches. These data, the first to explore how infertility patients decide whether, how and why to consult with more than one infertility doctor, suggest that patients may 'doctor shop,', engaging in dynamic processes, wrestling to weigh communication vs. other skills. These data have important implications for future practice, research, guidelines and education.

"Will they be good enough parents?": Ethical dilemmas, views, and decisions among assisted reproductive technology (ART) providers

BACKGROUND

Many adults may make less-than-ideal parents, but important ethical questions arise concerning whether assisted reproductive technology (ART) providers should thus ever refuse treatment to certain patients, and if so, when, and how to decide.

METHODS

In-depth interviews of approximately 1 hour each were conducted with 27 ART providers (17 physicians, and 10 other health providers).

RESULTS

Clinicians often struggle with whether to attempt to assess and predict patients' potential future parenting abilities, and if so, how, and how to proceed if doubts arise. Providers face profound ethical tensions between adults' rights to reproduce and best interests of the eventual children (i.e., to be born into "stable" homes), and questions about the extent of professional responsibilities toward potential parents versus toward future offspring. Providers generally feel uncomfortable with this role, and hence don't want it, partly since they lack training for it, but also because of inherent empirical and ethical uncertainties. Concerns about discrimination based on the mere presence or history of certain diagnoses or traits (e.g., single marital status or past depression) also arise. Clinicians frequently seek to resolve these tensions through various strategies-for example, referring these decisions to others; hoping that patients drop out of treatment; assessing and increasing social support (e.g., arranging for possible co-parents); assisting the patient psychotherapeutically; or seeking to communicate concerns to patients only indirectly or implicitly. Clinics vary in how they make and approach these decisions-whether they rely on a formal ethics or other committee.

CONCLUSIONS

These data, the first to explore several critical aspects of in vitro fertilization (IVF) providers' views and decision making about assessing the quality of patients' potential future parenting, have critical implications for future practice, education, research, and guidelines. Further empirical and normative scholarship and guidelines are needed to help clarify expectations, processes, and possible approaches to aid providers and patients.

Unconventional combinations of prospective parents: ethical challenges faced by IVF providers

Background

Professional guidelines have addressed ethical dilemmas posed by a few types of nontraditional procreative arrangements (e.g., gamete donations between family members), but many questions arise regarding how providers view and make decisions about these and other such arrangements.

Methods

Thirty-seven ART providers and 10 patients were interviewed in-depth for approximately 1 h each. Interviews were systematically analyzed.

Results

Providers faced a range of challenges and ethical dilemmas concerning both the content and the process of decisions about requests for unconventional interfamilial and other reproductive combinations. Providers vary in how they respond — what they decide, who exactly decides (e.g., an ethics committee or not), and how — often undergoing complex decision-making processes. These combinations can involve creating or raising the child, and can shift over time — from initial ART treatment through to the child’s birth. Patients’ requests can vary from fully established to mere possibilities. Arrangements may also be unstable, fluid, or unexpected, posing challenges. Difficulties emerge concerning not only familial but social, combinations (e.g., between friends). These arrangements can involve blurry and confusing roles, questions about the welfare of the unborn child, and unanticipated and unfamiliar questions about how to weigh competing moral and scientific concerns — e.g., the autonomy of the individuals involved, and the potential risks and benefits. Clinicians may feel that these requests do not “smell right”; and at first respond with feelings of “yuck,” and only later, carefully and explicitly consider the ethical principles involved. Proposed arrangements may, for instance, initially be felt to involve consanguineous individuals, but not in fact do so. Obtaining and verifying full and appropriate informed consent can be difficult, given implicit familial and/or cultural expectations and senses of duty. Social attitudes are changing, yet patients’ views of these issues may also vary, based on their cultural backgrounds.

Conclusions

These data, the first to examine how clinicians make decisions about unconventional reproductive arrangements, highlight several critical ethical questions and ambiguities, and variations in clinicians’ responses. While several professional guidelines exist, the current data highlight additional challenges, and have vital implications for improving future guidelines, practice, education and research.

Trial registration

Not applicable.

How much is a child worth? Providers' and patients' views and responses concerning ethical and policy challenges in paying for ART

Infertility treatments remain expensive and in many countries are covered by little, if any, insurance, raising critical questions concerning how patients and providers view and make decisions regarding these challenges. In-depth semi-structured interviews of approximately 1 hour were conducted with 37 IVF providers and 10 patients (17 physicians, 10 other providers and 10 patients), and were systematically analyzed. These data suggest current insurance policies and legislation pose critical ethical and logistical challenges for both patients and providers. These individuals face multiple uncertainties about costs and insurance, related to unclear causes of fertility, treatment length, costs and outcomes, and odds that insurers will cover expenses. Insurers frequently decline to agree to reimbursement beforehand, and decide only afterwards, case-by-case, generating stress. Patients and providers thus may not be able to predict how best to allocate limited resources. Providers may advocate for patients, but are usually unsuccessful. Patients may adopt several strategies: e.g., moving/seeking treatment elsewhere, switching or feeling "stuck" in jobs because of insurance, seeking "free" medications, going into debt, or using funds intended for other purposes. Patients do not perceive and respond to resource limitations as fixed phenomena-i.e., patients do not see treatment simply as "affordable" or not. Rather, patients face quandaries of how much to keep spending-how much a child is worth-and are forced to make complex risk/benefit calculations. Couples can disagree, straining relationships. In sum, these data, the first to explore how providers and patients struggle, view, and make decisions regarding limited insurance and resources for infertility, raise several critical ethical and policy issues. These data suggest that individuals have difficulty translating profoundly life-altering, deeply personal quests for meaning and fulfillment into purely economic terms. These findings thus have important implications for future policy, practice, research, and patient and provider education.