The crafting of hope: Contextualising add-ons in the treatment trajectories of IVF patients

Analysing adherence to guidelines for time-lapse imaging information on UK fertility clinic websites

This study aims to systematically analyze the provision of information on Time-lapse Imaging (TLI) by UK fertility clinic websites. We conducted an analysis of 106 clinic websites that offer fertility treatment to self-funded patients. The analysis aimed to examine whether these clinics offer TLI, the associated cost for patients, and the clarity and quality of the provided information. Out of the 106 websites analysed, 71 (67%) claimed to offer TLI. Among these websites, 25 (35.2%) mentioned charging patients between £300 and £850, 25 (35.8%) claimed not to charge patients, and 21 (29.6%) did not provide any cost information for TLI. Furthermore, 64 (90.1%) websites made claims or implied that TLI leads to improved clinical outcomes by enhancing embryo selection. Notably, 34 (47.9%) websites did not mention or provide any links to the HFEA rating system. It is crucial to provide patients with clear and accurate information to enable them to make fully informed decisions about TLI, particularly when they are responsible for the associated costs. The findings of this study raise concerns about the reliability and accuracy of the information available on fertility clinic websites, which are typically the primary source of information for patients.

Therapeutic value in the time of digital brainwaves

This article examines the value of medical technology through the case of electroencephalograms (EEGs), devices used to visualize brain activity and diagnose seizures. Drawing on ethnographic fieldwork, the article shows that EEGs are valued differently by patients and medical practitioners. While practitioners value EEGs for their clinical utility, i.e., ability to inform clinical decisions, patients value EEGs even in the absence of clinical utility. Indeed, patients derive long-lasting therapeutic effects from this diagnostic technology. These findings intervene in the utilitarian calculus of therapeutic value-a mode of reasoning that equates value with clinical utility-commonly deployed in biomedicine and engineering and call for a recognition of alternative notions such as the therapeutic value of being witnessed and cared for by medical experts via EEGs and other technologies that require time to work. Expansive notions of therapeutic value are imperative for including marginalized patients-especially low-income, disabled, and women patients-in debates on automation and the future of healthcare. Studying how multiple stakeholders value a medical technology provides insight into valuation, objectification, expertise, and other concerns central to science and technology studies.

Moral justification for the use of 'add-ons' in assisted reproductive technology: experts' views and experiences

RESEARCH QUESTION

What factors do assisted reproductive terchnology (ART) providers take into account when they make decisions about offering 'add-ons'?

DESIGN

A qualitative analysis of interviews with 31 ART professionals, focusing on their views and experiences in relation to add-ons, including the factors that are considered when doctors make decisions about their use.

RESULTS

The participants reported that a range of considerations are taken into account when it comes to justifying the use of a particular add-on in a given circumstance, including the likelihood of benefit and harm, patients' perceived psychological needs and preferences, and organizational expectations. Importantly, patient preferences, psychological factors and low risk of harm appear to be stronger motivations than increasing the likelihood of a live birth or the desire to innovate.

CONCLUSIONS

These findings suggest that it cannot be taken for granted that add-ons and innovation are closely linked. One possible response to this would be regulatory reform; for example, only allowing 'unproven' add-ons to be used in the context of formal scientific evaluation. Alternatively, it could be made clear that add-ons that are not undergoing formal evaluation have more in common with other therapies lacking a clear evidence base, such as complementary and alternative medicines, than with conventional medical practice. Practices in relation to add-ons may also require a focus on the responsibilities of corporations, and the standards applying to purveyors of consumer goods and services.

What do women undergoing in vitro fertilization (IVF) understand about their chance of IVF success?

STUDY QUESTION

How well informed are Australian women who undergo IVF about their chances of having a baby?

SUMMARY ANSWER

Only one in four women estimated their individual chance of success with IVF accurately, with most women overestimating their chance.

WHAT IS KNOWN ALREADY

Limited knowledge about infertility and infertility treatment in the general population is well-documented. The few studies that have investigated patients' knowledge about the chance of IVF success suggest that while IVF patients are aware of average success rates, they tend to be unrealistic about their own chance of success.

STUDY DESIGN, SIZE, DURATION

We conducted an anonymous online survey of 217 women who had started IVF since 2018 in Australia. The survey was advertised on social media, enabling women from across Australia to participate. Responses were collected in June 2021.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The survey included questions on demographic characteristics and IVF history. It asked what participants thought their chance of having a baby from one IVF treatment cycle was, how they rated their knowledge about chance of success, and about their experience of receiving IVF-related information. Participants' estimations of their chance of success were compared with their chance as calculated by the Society for Assisted Reproductive Technology's (SART) online calculator. Responses to a free-text question about what information women wished they had been given when they started treatment were analysed thematically.

MAIN RESULTS AND THE ROLE OF CHANCE

Only about a quarter (58/217, 27%) of participants accurately estimated their chance of having a baby within 20% relative to their SART calculated chance, with more than half (118/217, 54%) overestimating their chance. Ninety percent of women indicated that their preferred source of treatment information was a consultation with their doctor, despite less than half (44%) reporting that doctors explained the probability of having a baby with IVF well (mean 5.9/10). In free-text responses, many women also reported that they wished they had been given more realistic information about IVF and their chance of success.

LIMITATIONS, REASONS FOR CAUTION

The dissemination method precludes calculation of response rate, and it is not possible to know if participants are representative of all women undergoing IVF. Additionally, we only surveyed women undergoing IVF, while those who decided not to have IVF were not included. Therefore, women who overestimated their chance may have been overrepresented. There is also inherent imprecision in the way understanding of chance of success was estimated. The potential impact of recall bias could neither be quantified nor excluded. It is difficult to determine to what extent women's lack of understanding of what is possible with IVF is due to poor information-provision by clinicians and the clinic, and how much can be explained by optimism bias.

WIDER IMPLICATIONS OF THE FINDINGS

The finding of poor understanding of personal chance of success amongst women undergoing IVF in Australia requires further investigation to determine potential reasons for this. The findings can be used by clinics to develop strategies for improvement in the information-provision process to ensure that women can make informed decisions about their fertility treatment.

STUDY FUNDING/COMPETING INTEREST(S)

This study received no external funding. S.L. is supported by a NHMRC Investigator Grant (APP1195189). R.W. is supported by a NHMRC Investigator Grant (APP2009767). B.W.M. is supported by a NHMRC Investigator Grant (GNT1176437). B.W.M. reports consultancy for Merck and ObsEva and has received research funding and travel funding from Merck. The other authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Is the use of IVF add-on treatments driven by patients or clinics? Findings from a UK patient survey

There are conflicting narratives over what drives demand for add-ons. We undertook an online survey of IVF patients to determine whether patients perceive that use of IVF add-ons is driven by patients or practitioners. People who underwent IVF in the UK in the previous five years were recruited via social media Survey questions focussed on the roles of clinician offer and patient request, including who first suggested use of add-ons in IVF consultations, where patients first heard about them, and which information sources they trusted. From a total of 261 responses, 224 met the inclusion criteria. Overall, 67% of respondents had used one or more IVF add-ons, most commonly: time-lapse imaging (27%), EmbryoGlue (27%), and endometrial scratching (26%). Overall, 81% of the add-ons used were offered to participants by clinicians (compared to 19% requested by themselves). Half (54%) reported being offered add-ons during consultations, compared to 24% who initiated discussion about add-ons. Higher proportions of private patients reported being offered (90%), requesting (47%) and using (74%) add-ons than those with NHS funding (74%, 29%, 52%, respectively). The main limitations of this study are the small sample size, recruitment via a convenience sample, and the self-reported data capture which is subject to recall bias.

Accounting for complexity in healthcare innovation debates: Professional views on the use of new IVF treatments

Social scientists have long been interested in the forces and values driving healthcare innovation. The simultaneous rise of 20th century healthcare reforms, increased importance of evidence and upsurge in lay health activism have shaped modern medicine. On this backdrop, fertility care emerged in the 1970s. Recent developments reveal a contentious relationship between new fertility treatments and clinical evidence, with emerging technologies being used without conclusive evidence of effectiveness despite being sold to patients. Initial critiques of this phenomenon emphasise commercial interests as the culprit, suggesting that the problematic use of unproven treatments is mainly driven by the private sector. Here, we challenge this over-simplified view of IVF care. Drawing on a qualitative analysis of key documents and 43 in-depth professional interviews, this article identifies three main stakeholder approaches to new treatment adoption. We argue that viewpoints are anchored within three critical overarching 'modes of coordination' or core values in modern healthcare: efficiency, effectiveness and patient-centeredness. This analysis encourages a more contextualised overview of fertility care than previous literatures have afforded. The IVF case shows that an emphasis on private versus public clinic practices obscure similarities between the two along with the values motivating healthcare professionals' approaches to new treatments.

Hope and Exploitation in Commercial Provision of Assisted Reproductive Technologies

Innovation is a key driver of care provision in assisted reproductive technologies (ART). ART providers offer a range of add-on interventions, aiming to augment standard in vitro fertilization protocols and improve the chances of a live birth. Particularly in the context of commercial provision, an ever-increasing array of add-ons are marketed to ART patients, even when evidence to support them is equivocal. A defining feature of ART is hope-hope that a cycle will lead to a baby or that another test or intervention will make a difference. Yet such hope also leaves ART patients vulnerable in a variety of ways. This article argues that previous attempts to safeguard ART patients have neglected how the use of add-ons in commercial ART can exploit patients' hopes. Commercial providers of ART should provide add-ons only free of charge, under a suitable research protocol.

In praise of ovulation induction for the management of anovulatory subfertility

Rapid advances in assisted reproductive technology have revolutionized fertility treatments for couples worldwide seeking a pregnancy. Although this is promising, concerns are emerging over the overuse of unnecessary assisted conception treatments, particularly among couples with anovulatory subfertility. Some experts are calling for the cessation of ovulation induction as the primary treatment of anovulatory subfertility in favour of more sophisticated assisted conception treatments. In the absence of other causes of subfertility, ovulation induction in patients with type 1 and type 2 anovulation disorders can achieve an up to 80% ovulation rate with a 40% cumulative pregnancy rate and few adverse effects. Considering the various risks and high costs associated with assisted reproductive technology treatments, it is hard to argue for their cost-effectiveness when simpler, safer and cheaper pharmacological ovulation induction could achieve comparable pregnancy rates. We argue here for the safe, effective and ethical use of ovulation induction in this population, supplemented by a judicious use of assisted conception treatments. We emphasize the essential role of ovulation induction as a first-line intervention for couples with anovulatory subfertility delivered within a patient-centred multidisciplinary care model and with a clear escalation pathway to use assisted reproductive technology treatments based on the person's response, characteristics and treatment preference.

Fertility specialists' views, behavior, and attitudes towards the use of endometrial scratching in Italy

BACKGROUND

Endometrial scratching (ES) or injury is intentional damage to the endometrium performed to improve reproductive outcomes for infertile women desiring pregnancy. Moreover, recent systematic reviews with meta-analyses and randomized controlled trials demonstrated that ES is not effective, data on the safety are limited, and it should not be recommended in clinical practice. The aim of the current study was to assess the view and behavior towards ES among fertility specialists throughout infertility centers in Italy, and the relationship between these views and the attitudes towards the use of ES as an add-on in their commercial setting.

METHODS

Online survey among infertility centers, affiliated to Italian Society of Human Reproduction (SIRU), was performed using a detailed questionnaire including 45 questions with the possibility to give "closed" multi-choice answers for 41 items and "open" answers for 4 items. Online data from the websites of the infertility centers resulting in affiliation with the specialists were also recorded and analyzed. The quality of information about ES given on infertility centers websites was assessed using a scoring matrix including 10 specific questions (scored from 0 to 2 points), and the possible scores ranged from 0 to 13 points ('excellent' if the score was 9 points or more, 'moderate' if the score was between 5 and 8, and 'poor' if it was 4 points or less).

RESULTS

The response rate was of 60.6% (43 questionnaires / 71 infertility SIRU-affiliated centers). All included questionnaires were completed in their entirety. Most physicians (~ 70%) reported to offer ES to less than 10% of their patients. The procedure is mainly performed in the secretory phase (69.2%) using pipelle (61.5%), and usually in medical ambulatory (56.4%) before IVF cycles to improve implantation (71.8%) without drugs administration (e.g., pain drugs, antibiotics, anti-hemorrhagics, or others) before (76.8%) or after (64.1%) the procedure. Only a little proportion of infertility centers included in the analysis proposes formally the ES as an add-on procedure (9.3%), even if, when proposed, the full description of the indications, efficacy, safety, and costs is never addressed. However, the overall information quality of the websites was generally "poor" ranging from 3 to 8 and having a low total score (4.7 ± 1.6; mean ± standard deviation).

CONCLUSIONS

In Italy, ES is a procedure still performed among fertility specialists for improving the implantation rate in IVF patients. Moreover, they have a poor attitude in proposing ES as an add-on in the commercial setting.

Patient and professional perspectives about using in vitro fertilisation add-ons in the UK and Australia: a qualitative study

OBJECTIVES

In vitro fertilisation (IVF) add-ons are additional procedures offered alongside an IVF cycle with the aim of improving live birth rates. They are controversial because of the paucity of evidence to support their efficacy and safety, alongside the additional financial cost they often pose to patients. Despite this, they are popular. However, there is limited qualitative research regarding their use. The aims of the VALUE Study were to understand the decision-making process surrounding using or recommending add-ons; report sources of information for add-ons; and explore concerns for safety and effectiveness when considering their use.

DESIGN

'VALUE' is a qualitative semistructured interview study using inductive thematic analysis of anonymised transcriptions.

SETTING

Participants were recruited from a broad geographical spread across the UK and Australia from public and private clinical settings.

PARTICIPANTS

Patients (n=25) and health professionals (embryologists (n=25) and clinicians (n=24)) were interviewed. A purposive sampling strategy was undertaken. The sampling framework included people having state-subsidised and private cycles, professionals working in public and private sectors, geographical location and professionals of all grades.

RESULTS

Patients often made decisions about add-ons based on hope, minimising considerations of safety, efficacy or cost, whereas professionals sought the best outcomes for their patients and wanted to avoid them wasting their money. The driving forces behind add-on use differed: for patients, a professional opinion was the most influential reason, whereas for professionals, it was seen as patient driven. For both groups, applying the available evidence to individual circumstances was very challenging, especially in the sphere of IVF medicine, where the stakes are high.

CONCLUSIONS

There is scope to build on the quality of the discourse between patients and professionals. Patients describe valuing their autonomy with add-ons, but for professionals, undertaking informed consent will be critical, no matter where they sit on the spectrum regarding add-ons.

TRIAL REGISTRATION

osf.io/vnyb9.

Patient informed choice in the age of evidence-based medicine: IVF patients' approaches to biomedical evidence and fertility treatment add-ons

With the increasing offer of fertility treatment by a largely privatised sector, which has involved the proliferation of treatment add-ons lacking evidence of effectiveness, In-Vitro Fertilisation (IVF) patients are expected to make informed choices on what to include in their treatment. Drawing on interviews with 51 individuals undergoing fertility treatment, this article explores patients' approaches to medical evidence interpretation and its role in their decisions to include add-ons. While most IVF patients share understandings of what counts as medical evidence, our findings show how their approaches also differ. Our analysis focuses on how patients negotiate the notion of medical evidence and its relation to other forms of experience or knowledge. We present four different approaches to evidence in IVF: (1) delegating evaluations of evidence to experts; (2) critically assessing available evidence; (3) acknowledging the process of making evidence; and (4) contextualising evidence in their lived experience of infertility. We suggest that patients' choice to include add-ons is not due to a lack of information on or understanding of evidence, but rather should be interpreted as part of the complexity of patients' experiences of infertility.

What Features of Fertility Treatment do Patients Value? Price Elasticity and Willingness-to-Pay Values from a Discrete Choice Experiment

BACKGROUND

Infertility is a medical condition affecting an estimated 186 million people worldwide. Medically assisted fertility treatments allow many of these individuals to have a baby. Insights about preferences of patients who have experienced fertility treatment should be used to inform funding policies and treatment configurations that best reflect the patients' voice and the value of fertility treatment to patients.

OBJECTIVE

To explore the preferences for fertility treatment attributes of infertile women who had previously undergone or were undergoing fertility treatments-ex post perspective.

METHODS

We used data from a stated-preference discrete choice experiment (DCE) among 376 Australian women who had undergone or were undergoing fertility treatment. Respondents chose their preferred treatment choices in 12 hypothetical treatment choice scenarios described by seven attributes (success rates, side effects, counselling/peer support, treatment journey, continuity of care, availability of experimental treatment and out-of-pocket cost). We estimated random parameter logit (RPL) and latent class (LC) models that accounted for preference heterogeneity. The results were used to derive price elasticities of demand and marginal willingness-to-pay (WTP) values for the treatment attributes explored within the DCE survey.

RESULTS

Income level did not have a significant effect on marginal WTP for fertility treatment attributes. The demand for fertility treatment from an ex post perspective was found to be highly inelastic (treatment cost changes had almost no impact on demand). Success rates and out-of-pocket costs were significant and important predictors of individuals' treatment choices conditional on the attributes and levels included in the study. These were followed by counselling/peer support, side effects, treatment journey, continuity of care, and availability of experimental treatment, in that order. Respondents were willing to pay $383-$524 per one percentage point increase in the treatment success rate and over $2000 and over $3500 to avoid moderate and significant side effects, respectively (values are reported in AU$). Latent class models revealed that the majority of respondents (51%) were risk-averse success-rate seekers.

CONCLUSION

Infertile women who had previously undergone or were undergoing fertility treatment valued fertility treatment highly as reflected by highly price-inelastic demand. Success rate of treatment and out-of-pocket costs were the most important attributes and largely determined patients' WTP for fertility treatment relative to the attributes and levels used in the study. While further research should investigate the price sensitivity of women who have not experienced fertility treatment, these results might explain why women continue fertility treatment once they have commenced despite their financial capacity to pay. Future research should also determine patients' price elasticities for a fertility treatment program with multiple treatment cycles.

'A platform for goodness, not for badness': The heuristics of hope in patients' evaluations of online health information

Patient advocates and activists are increasingly relying on online health information that can assist them to manage their health condition. Yet once online, they will confront diverse information whose veracity and utility are difficult to determine. This article offers a sociological analysis of the practical methods, or heuristics, that patient advocates and activists use when making judgements about the credibility and utility of online information. Drawing on the findings from interviews with fifty Australian patient advocates and activists, it is argued that these individuals' use of these heuristics reflects their hopes that information can help them manage their condition which may, in some cases, override fears and uncertainties that arise during searches. The article identifies the common 'rules-of-thumb'-or what we call the 'heuristics of hope'-that patient advocates/activists may use to make judgements and highlights the dangers of over-reliance on them, especially regarding clinically unproven, potentially unsafe treatments. Analyses of the heuristics of hope, we conclude, can assist in understanding the dynamics of decision-making and the role that affect plays in online patient communities which is crucial in an age characterised by the rapid circulation of emotionally charged messages, often based on hope.