Information provision and decision-making in assisted reproduction treatment: results from a survey in Germany

Fertility clinics have a duty of care towards patients who do not have children with treatment

In medically assisted reproduction (MAR) success has mostly been measured in terms of achieving (healthy) livebirths. We argue this focus is too narrow and that success should be measured in terms of alleviating patient suffering caused by an unfulfilled child wish. The major implication is that clinics must better tailored care to effectively support patients who do not have child(ren) with treatment. First, we argue that clinics have a duty of care towards patients for whom MAR does not result in children because this is a common treatment outcome, because treatment is burdensome and creates new losses for patients, and because the field has the necessary expertise to provide support and it is part of patient-centred care. Then, we examine concerns about the adequacy of addressing the possibility that treatment may end without children, namely, that this may hinder patients' hope and put them off doing treatment, and that it may be perceived as a sign of clinical incompetence, as well as concerns about the required skill set. We end with a set of research-informed recommendations to promote healthy adjustment to ending fertility treatment without children. These focus on the need to reconceptualize 'success' and 'failure' in MAR, to promote open discussion about the possibility of treatment not resulting in children and encourage patients to develop 'plan(s) B', to support patients who end treatment without children, and to create the organizational structures needed to support clinics and healthcare professionals in this endeavour.

Reframing as recourse: How women approach and initiate the end of fertility treatment

Hopeful parents facing infertility dedicate significant sums of money, not to mention time, energy, and their own bodies, in the pursuit of biological parenthood via assisted reproductive technology (ART). Yet because the success rate of ART varies depending on a range of factors and resources remain finite, many undergoing treatment will not manage to biologically conceive. How do people who do not conceive with ART come to terms with this reality and the possibility that they may need to walk away from future treatments? Supplementing prior research that explores why women end treatment and what makes it difficult, this study draws upon 23 semi-structured, in-depth interviews to examine how women diagnosed with infertility consider and/or initiate discontinuation of treatment aimed at biological reproduction. I find that women employ three core reframing strategies as they approach the end of treatment: broadening their anticipatory future, adjusting their investment logic, and recentering and decentering the self. These rhetorical techniques not only illuminate the evolving interpretive work that undergirds the process of discontinuation, but also constitute a key mechanism facilitating the ending of treatment-linking cognition with social action and shedding light on the mechanics of decision reversals. Moreover, the practice of reframing challenges the pervasive assumption that discontinuation is wholly or chiefly disempowering to women.

Discussing the possibility of fertility treatment being unsuccessful as part of routine care offered at clinics: patients' experiences, willingness, and preferences

STUDY QUESTION

Are patients willing to discuss the possibility of treatment being unsuccessful as part of routine care offered at clinics, and what are the factors associated with this willingness?

SUMMARY ANSWER

Nine in every 10 patients are willing to discuss this possibility as part of routine care, with willingness being associated with higher perceived benefits, lower barriers, and stronger positive attitudes towards it.

WHAT IS KNOWN ALREADY

Fifty-eight percent of patients who complete up to three cycles of IVF/ICSI in the UK do not achieve a live birth. Offering psychosocial care for unsuccessful fertility treatment (PCUFT), defined as assistance and guidance on the implications of treatment being unsuccessful, could reduce the psychosocial distress patients experience when it happens, and promote positive adjustment to this loss. Research shows 56% of patients are willing to plan for an unsuccessful cycle, but little is known about their willingness and preferences towards discussing the possibility of definitive unsuccessful treatment.

STUDY DESIGN, SIZE, DURATION

The study was of cross-sectional design, comprising a theoretically driven and patient-centred bilingual (English, Portuguese) mixed-methods online survey. The survey was disseminated via social media (April 2021-January 2022). Eligibility criteria included being aged 18 or older, waiting to or undergoing an IVF/ICSI cycle, or having completed a cycle within the previous 6 months without achieving a pregnancy. Out of 651 people accessing the survey, 451 (69.3%) consented to participate. From these, 100 did not complete 50% of the survey questions, nine did not report on the primary outcome variable (willingness), and 342 completed the survey (completion rate 75.8%, 338 women).

PARTICIPANTS/MATERIALS, SETTING, METHODS

The survey was informed by the Health Belief Model (HBM) and Theory of Planned Behaviour (TPB). Quantitative questions covered sociodemographic characteristics and treatment history. Quantitative and qualitative questions gathered data on past experiences, willingness, and preferences (with whom, what, how and when) to receive PCUFT, as well as theory-informed factors hypothesized to be associated with patients' willingness to receive it. Descriptive and inferential statistics were used on quantitative data about PCUFT experiences, willingness, and preferences, and thematic analysis was applied to textual data. Two logistic regressions were used to investigate the factors associated with patients' willingness.

MAIN RESULTS AND THE ROLE OF CHANCE

Participants were, on average, 36 years old and most resided in Portugal (59.9%) and the UK (38.0%). The majority (97.1%) were in a relationship for around 10 years, and 86.3% were childless. Participants were undergoing treatment for, on average, 2 years [SD = 2.11, range: 0-12 years], with most (71.8%) having completed at least one IVF/ICSI cycle in the past, almost all (93.5%) without success. Around one-third (34.9%) reported having received PCUFT. Thematic analysis showed participants received it mainly from their consultant. The main topic discussed was patients' low prognosis, with the emphasis being put on achieving a positive outcome. Almost all participants (93.3%) would like to receive PCUFT. Reported preferences indicated that 78.6% wanted to receive it from a psychologist/psychiatrist/counsellor, mostly in case of a bad prognosis (79.4%), emotional distress (73.5%), or difficulties in accepting the possibility of treatment being unsuccessful (71.2%). The preferred time to receive PCUFT was before initiating the first cycle (73.3%), while the preferred format was in an individual (mean = 6.37, SD = 1.17; in 1-7 scale) or couple (mean = 6.34, SD = 1.24; in 1-7 scale) session. Thematic analysis showed participants would like PCUFT to provide an overview of treatment and all possible outcomes tailored to each patient's circumstances and to encompass psychosocial support, mainly focused on coping strategies to process loss and sustain hope towards the future. Willingness to receive PCUFT was associated with higher perceived benefit of building psychosocial resources and coping strategies (odds ratios (ORs) 3.40, 95% CI 1.23-9.38), lower perceived barrier of triggering negative emotions (OR 0.49, 95% CI 0.24-0.98), and stronger positive attitudes about PCUFT being beneficial and useful (OR 3.32, 95% CI 2.12-5.20).

LIMITATIONS, REASONS FOR CAUTION

Self-selected sample, mainly composed of female patients who had not yet achieved their parenthood goals. The small number of participants unwilling to receive PCUFT reduced statistical power. The primary outcome variable was intentions, and research shows a moderate association between intentions and actual behaviour.

WIDER IMPLICATIONS OF THE FINDINGS

Fertility clinics should provide patients with early opportunities to discuss the possibility of their treatment being unsuccessful as part of routine care. PCUFT should focus on minimizing suffering associated with grief and loss by reassuring patients they can cope with any treatment outcome, promoting coping resources, and signposting to additional support.

STUDY FUNDING/COMPETING INTEREST(S)

M.S.-L. holds a doctoral fellowship from the Portuguese Foundation for Science and Technology, I.P. [Fundação para a Ciência e a Tecnologia] (FCT; SFRH/BD/144429/2019). R.C. holds a post-doctoral fellowship supported by the European Social Fund (ESF) and FCT (SFRH/BPD/117597/2016). The EPIUnit, ITR and CIPsi (PSI/01662) are also financed by FCT through the Portuguese State Budget, in the scope of the projects UIDB/04750/2020, LA/P/0064/2020 and UIDB/PSI/01662/2020, respectively. Dr Gameiro reports consultancy fees from TMRW Life Sciences and Ferring Pharmaceuticals A/S, speaker fees from Access Fertility, SONA-Pharm LLC, Meridiano Congress International and Gedeon Richter, grants from Merck Serono Ltd, an affiliate of Merck KgaA, Darmstadt, Germany.

TRIAL REGISTRATION NUMBER

N/A.

Qualitative evaluation of the acceptability and feasibility among healthcare professionals and patients of an ART multi-cycle treatment planning and continuation intervention prototype

STUDY QUESTION

Is it possible to design an ART Treatment Planning and Continuation Intervention (TPCI) that is considered acceptable and feasible to patients and healthcare professionals (HCPs)?

SUMMARY ANSWER

HCPs and patients responded positively to the TPCI prototype and perceived it as an acceptable intervention to support patients to stay engaged with planned treatment, but some concerns were raised about the feasibility of using it in practice.

WHAT IS KNOWN ALREADY

People discontinue ART due to its psychological burden. Digital tools to support people undergoing ART are available but typically focus only on practical support rather than psychological support. Research about treatment continuation and multi-cycle planning indicates that cognitive factors (expectations, intentions, efficacy beliefs) should be targets of interventions designed to help patients engage with and continue treatment to meet their personal treatment plans and goals. However, it is not known whether this form of psychological support would be acceptable for HCPs and patients or feasible to implement in practice.

STUDY DESIGN, SIZE, DURATION

Qualitative cognitive interviews with HCPs and patients (May 2021). Patients were eligible if they had had a consultation to start a first/repeat stimulated IVF/ICSI cycle in the 8 weeks prior to recruitment, were aged 18 or older (upper age limit of 42 years for women) and fluent in English. Eligible HCPs were those employed by a fertility clinic who were responsible for delivering treatment planning consultations to patients.

PARTICIPANTS/MATERIALS, SETTING, METHODS

HCPs and patients were asked to think aloud while being exposed to and exploring the TPCI in one-to-one online cognitive interviews. The TPCI was designed to reduce treatment discontinuation via cognitive factors namely formation and maintenance of multi-cycle ART intentions and efficiency of decision-making during treatment, and continuation of treatment after an unsuccessful cycle (when recommended). To impact cognitive factors the TPCI comprised of two components: an expectation management and reasoning checklist for HCPs to use during planning consultations (TPCI Checklist) and a multi-feature cognitive support mobile application (TPCI App) for patients to use prior to and during treatment. After participants thought aloud while being exposed to the TPCI prototype (both components) they were asked open questions concerning their perceptions of the core components and activities on eight acceptability dimensions (e.g. acceptability, demand, integration). Interviews lasted between 40 and 90 min, were recorded, transcribed verbatim and analysed using thematic analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

Thirteen HCPs and 13 patients participated in 25 online interviews. Thematic analysis using inductive and deductive coding generated 180 codes, grouped into 22 categories and synthesized into 9 themes. The themes showed that HCPs and patients provided positive feedback about the TPCI, perceiving it as a needed, acceptable and potentially effective way to forewarn patients of the possible need for multiple cycles, to provide patients with a sense of patient-clinic collaboration and support, and to bolster treatment intentions, all of which were perceived to contribute to reduced treatment discontinuation. HCPs perceived implementation of the TPCI Checklist to be challenging in its current length due to time pressures and clinic workload. Suggestions for enhancing the TPCI Checklist and App were provided, but none required critical changes to its core components or activities.

LIMITATIONS, REASONS FOR CAUTION

All patients were women recruited from social media websites, mainly associated with patient support groups, who may be highly committed to their fertility treatment. HCPs were predominantly from private fertility clinics.

WIDER IMPLICATIONS OF THE FINDINGS

The findings suggest there is demand for digital support geared towards motivational aspects of undergoing ART. The TPCI is an acceptable support tool to meet that need according to HCPs responsible for delivering planning consultations and patients undergoing fertility treatment. Future research is needed to develop the prototype and examine the feasibility of implementation of the TPCI in clinics.

STUDY FUNDING/COMPETING INTEREST(S)

This research was financially supported by Merck Serono Ltd, an affiliate of Merck KGaA, Darmstadt, Germany. 'Merck KGaA, Darmstadt, Germany reviewed the manuscript for medical accuracy only before journal submission. The authors are fully responsible for the content of this manuscript, and the views and opinions described in the publication reflect solely those of the authors' J.B. reports personal fees from Merck KGaA, Darmstadt, Germany, Merck AB an affiliate of Merck KGaA, Darmstadt Germany, Theramex, Organon JJC, Ferring Pharmaceuticals A/S, research grant from Merck Serono Ltd, grants from ESHRE outside the submitted work and that she is co-developer of Fertility Quality of Life (FertiQoL) and MediEmo app. S.G. reports consultancy fees from TMRW Life Sciences and Ferring Pharmaceuticals A/S, speaker fees from Access Fertility, SONA-Pharm LLC, Meridiano Congress International and Gedeon Richter. C.H. declares no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Perceptions of Fertility Physicians Treating Women Undergoing IVF Using an Egg Donation

In the course of their work, medical teams are routinely exposed to difficult and stressful situations. The few studies in the literature that have examined physicians’ perceptions and responses to such situations have focused primarily on the fields of emergency medicine and chronic and terminal illness. However, the field of fertility medicine can also evoke complex feelings among physicians. The present qualitative study examined the perceptions of fertility physicians treating women undergoing egg donation. Semi-structured in-depth interviews were conducted with 20 fertility physicians, and a categorical analysis was performed. The main category to emerge was the physicians’ perception of egg donation and its implications. Two prominent themes were identified within this category: doctor–patient communication surrounding egg donation and how the idea was presented to the patient; and doctors’ perception of the implications of egg donation, including maternal identity, the relationship between mother and infant, and the mother’s sense of the child’s identity. This is the first study to consider the response to fertility treatments, a contemporary and sensitive topic, from the perspective of the physicians. The findings can contribute to physicians’ understanding of themselves and can help to devise ways to assist them in managing their emotional responses to their work for the benefit of both themselves and their patients.

A Baby at All Costs? Exploring the Use and Provision of Unproven Adjuvant Treatments in the Context of IVF

The year 2018 marked 40 years since the birth of Louise Brown, the first baby born as a result of pioneering in vitro fertilization (IVF) treatment. Since then, advances have seen a wide range of reproductive technologies emerge into clinical practice, including adjuvant treatments often referred to as IVF "add-ons." However, these "optional extras" have faced growing criticism, especially when they have often come at additional financial cost to the patient and have little evidence supporting their efficacy to improve pregnancy or birth rates. Despite this, according to the latest national patient survey by the Human Fertilisation and Embryology Authority, three quarters of patients who had fertility treatment in the United Kingdom in the past two years had at least one type of treatment add-on highlighting the growing demand for these interventions. This article uses a psychosocial perspective to consider the motivations behind patient and clinician behavior along with the wider societal and economic factors that may be impacting upon the increase in the use of adjuvant treatments in fertility clinics more widely. It suggests the reasons fertility patients use unproven "optional extras" are complex, with interpersonal, psychological, and social factors intertwining to generate an increase in the use of IVF add-ons.

Patient willingness, preferences and decision-making about planning for three complete cycles of IVF/ICSI treatment

STUDY QUESTION

What is willingness, preference and decision-making about planning for the possibility of needing multiple cycles of IVF/ICSI treatment among patients consulting for a first or repeat stimulated IVF/ICSI cycle?

SUMMARY ANSWER

The majority of patients seem to value the opportunity to plan for multiple cycles of treatment while acknowledging both possible challenges and benefits of doing so and decisions that might need to be made in advance.

WHAT IS KNOWN ALREADY

Patients have strong intentions to do treatment to achieve pregnancy and approximately 48-54% continue treatment when confronted with a failed cycle, undergoing at least three complete cycles of treatment. However, there is inconsistency between this apparent willingness to do multiple cycles of treatment and the way treatment is currently planned on a cycle-by-cycle basis with patients.

STUDY DESIGN, SIZE, DURATION

The study was of cross-sectional design, comprising a mixed-methods English online survey posted between November 2019 and March 2020. Eligibility criteria were being a patient who had had a consultation to start a stimulated cycle of IVF/ICSI for the first time or for a repeat stimulated cycle after an unsuccessful cycle in the eight weeks prior to survey completion. Individuals were also required to be aged 18 or older (upper age limit of 42 years for women) and able to respond in English. In total 881 clicked on the survey link, 118 did not consent, 41 were excluded after data screening, 57 did not meet the inclusion criteria, 331 started the survey but did not complete it, 28 had missing data on critical variables (e.g., age) and 306 completed the survey (40.1% completion, 57 men, 249 women).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were allocated to either the willing or unwilling to plan for multiple cycles of treatment group based on their responses to three variables: willingness to plan for three complete cycles, whether they would choose to have another cycle of IVF and whether they would continue treatment after an unsuccessful cycle. Quantitative questions gathered data on preferences towards planning for multiple cycles (i.e., attitudes, subjective norms and perceived behavioural control), challenges, benefits of planning for multiple cycles, decisional conflict experienced and treatment decisions involved in planning for multiple cycles. Demographic, fertility and fertility treatment information were also collected. Qualitative questions gathered textual data on other perceived benefits and challenges of planning for multiple cycles and solutions to the challenges. Descriptive and inferential statistics were used on quantitative data. Thematic analysis (inductive coding) was performed on the textual data.

MAIN RESULTS AND THE ROLE OF CHANCE

Overall, 73.2% (n = 224) of participants had had a consultation to start a first cycle of IVF/ICSI. Participants were on average 33 years of age and had been trying to conceive for three years. A total of 63.07% (n = 193) were university educated. A total of 56% (n = 172) of participants were willing to plan for multiple cycles of IVF/ICSI in advance of treatment. Repeated measures ANOVA, t-tests and chi-square analysis showed the willing group to be significantly more likely to have been in a relationship for longer (p<.05), have higher education (p<.05) and be resident in the United Kingdom (p<.05). The willing group had positive attitudes towards planning for multiple cycles (p<.001) and stronger agreement with subjective norms (p<.001), perceived behavioural control (p<.001), benefits of planning for multiple cycles (p<.01) and felt able and attached more importance to making treatment decisions in advance of treatment (p<.05). Data saturation was achieved for the thematic analysis of textual data which revealed a total of four other challenges (e.g., less decisional freedom) and six other benefits (e.g., having a realistic view of treatment) to planning for multiple cycles. Qualitative analysis also revealed that most patients could anticipate and provide solutions for the nine challenges of planning for multiple cycles (e.g., using flexible working for the negative effect of treatment on work).

LIMITATIONS, REASONS FOR CAUTION

Limitations included the outcome measure being willingness to plan for multiple cycles rather than actual multi-cycle planning behaviour. The unwilling group represented a heterogeneous group with possibly unknown motivational coherence (e.g., definitely against planning, ambivalent about planning). Other limitations included the cross-sectional nature of the survey and the recruitment source.

WIDER IMPLICATIONS OF THE FINDINGS

Treatment consultations about undergoing fertility treatment could re-frame treatment to be a multi-cycle process in line with patient's willingness, preference and decision-making. This multi-cycle approach could empower patients and clinicians to discuss treatment expectations realistically and formulate fully informed treatment plans that take account of the high likelihood of cycle failure in addition to the treatment decisions that may need to be made during treatment when a cycle fails. This multi-cycle approach could help us support patients in adhering to their treatment plans even when faced with challenges, and help ascertain the level of treatment engagement possible to achieve parenthood goals.

STUDY FUNDING/COMPETING INTEREST(S)

This project is funded by an Investigator-Sponsor Non-interventional Study from Merck Serono Ltd (MS200059_0010). Professor Boivin reports personal fees from Merck KGaA, Darmstadt, Germany, Merck AB an affiliate of Merck KGaA, Darmstadt Germany, Theramex, Ferring Pharmaceuticals A/S, grant from Merck Serono Ltd, outside the submitted work and that she is co-developer of Fertility Quality of Life (FertiQoL) and MediEmo app. Dr. Gameiro reports consultancy fees from Ferring Pharmaceuticals A/S, Access Fertility and SONA-Pharm LLC, and grants from Merck Serono Ltd. Dr. Harrison declares no conflicts of interest.

TRIAL REGISTRATION NUMBER

n/a.

Informational needs of couples undergoing intracytoplasmic sperm injection with surgical sperm retrieval: A qualitative study

OBJECTIVE

Infertile couples consider patient information a very important dimension of patient-centred care. Although testicular sperm extraction (TESE) followed by intracytoplasmic sperm injection (ICSI) has long been offered to infertile couples, little is known about couples' informational needs. The aim of this study was to identify the informational needs of couples undergoing TESE and ICSI, including information content and the channels providing the information as a first step to improve patient-centred care.

STUDY DESIGN

We conducted a qualitative study consisting of semi-structured interviews with 11 couples. The topic guide was based on a literature review and interviews with an expert panel. The number of interviews was determined with data saturation. The data were analysed using a constant comparative method.

RESULTS

The couples needed information about many topics. They considered information about the success rates of the treatment, an explanation of the treatment procedure, and other patient experiences the most important. Regarding information channels, the couples preferred face-to-face information, but they also valued a leaflet, website, or an online application, especially when it is personalized or providing interactive functionalities.

CONCLUSION

We obtained in-depth insight into the information needs of couples undergoing TESE and ICSI. The results of this study give fertility clinics an opportunity to develop patient information that meets the needs of their patients and thus improve patient-centred fertility care.

Preferred problem solving and decision-making role in fertility treatment among women following an unsuccessful in vitro fertilization cycle

Background

While the literature on healthcare decision-making has long focused on doctor-patient interaction, fertility treatment is an exception, characterized by a triangular interplay between the doctor, the woman and her partner. This study examined treatment decision-making preferences of women undergoing in vitro fertilization (IVF) treatment, following an unsuccessful IVF cycle, especially their preferred level of doctor and spousal involvement.

Methods

A cross-sectional survey was conducted with 246 Chinese women undergoing IVF recruited from an assisted reproduction clinic of a university-affiliated hospital in Hong Kong. Data collection was conducted between January 2014 and August 2015.

Results

Most participants preferred sharing the decision-making tasks with their doctors (92%). In the doctor-patient relationship, passive roles were associated with higher marital satisfaction, presence of religious affiliation and secondary infertility, while autonomous roles were related to female-factor infertility. Fifty-two percent of participants anticipated sharing decision-making, while 46% preferred handing over the decision to their husbands. Preference for a passive rather than a shared role in the spousal relationship was related to a higher husband’s age, greater marital satisfaction and higher anxiety.

Conclusions

In brief, women tended to prefer sharing decision-making tasks with their doctor as well as actively engaging their partner in making decisions about fertility treatment. This study adds to our understanding of women’s role preference and level of involvement in infertility treatment decision-making by providing quantitative evidence from women’s experience. It highlights the importance of healthcare professionals in facilitating shared decision-making among couples.

Towards a more pragmatic and wiser approach to infertility care

Infertility represents a very peculiar area of medicine. Contrary to other areas, where signs and symptoms lead to a diagnosis, which in turn leads to a specific treatment, in reproduction the lack of signs and symptoms for more than 12 months suggests the diagnosis of ‘unexplained subfertility’, and if this condition has lasted for some years, couples qualify for IVF. Diagnosis and treatments can extend over long periods of time (even years) and the accuracy of the diagnostic armamentarium is not optimal. Uncertainty about diagnosis and the need for significant perseverance is demanding on both couples and physicians, and actually constitute a very favourable situation for overdiagnosis (‘unexplained subfertility’) and overtreatment (IVF) on one hand, and, on the other, it may also affect compliance with treatments. To improve our capacity to properly handle this challenging situation, increased attention should be given to the duration of pregnancy seeking. Initiating treatments earlier in older women is unwise because this population has a lower fecundity and, therefore, duration of pregnancy seeking is even more important to achieve a reliable diagnosis of infertility. Moreover, if the infertility work-up is unremarkable, duration of pregnancy seeking should be extended up to more than 2 years prior to making a diagnosis of unexplained infertility regardless of age. An adequate period of pregnancy seeking is also required for couples who are diagnosed with conditions that can interfere with fertility to avoid overdiagnosis and overtreatment. Indeed, most causes of infertility will reduce but not impair natural conception. Within this sometimes long-term management, physicians should also pay attention to detrimental life habits in order to optimize the chances of both natural and assisted reproduction technology -mediated pregnancy. Even if interventional studies are not conclusive, it is advisable to address the problems of obesity and smoking. Focussing on frequency of sexual intercourse may be also beneficial for natural conception. Finally, there is the need for improving our capacity to handle compliance. Providing information on the importance of persevering at the start of treatment, promoting shared decision-making and tackling patient, clinic and treatment causes of drop-out can all improve the overall chances of parenthood. Thus, we plead for a wiser and more pragmatic approach to infertility, paying more attention to these neglected, but in our opinion essential, aspects of infertility care.

Satisfaction with Information Provided to Infertile patient Who Undergo Assisted Reproductive Treatment

Background

Potentially modifiable factors, such as the appropriate informing process given to infertile patients, can affect their infertility knowledge and information. This study aims to assess infertility information provided to Irani- ans who undergo assisted reproductive treatment.

Materials and Methods

In this cross-sectional study, participants recruited were a convenience sample of all infer- tile patients who received assisted reproductive treatments from Royan Institute, Tehran, Iran. Inclusion criteria con- sisted of: patient’s first time visit, no previous infertility treatment failures, and referral to the centre between January and March 2015. A 20-item tool designed by researchers measured patient satisfaction with the infertility informing process. This tool included cause of infertility, type of recommended treatment, diagnostic procedures, approximate treatment duration, success rate of the treatment, approximate cost of treatment, and non-therapeutic factors in treat- ment success.

Results

A total of 235 infertile patients were invited to participate in the study, from which 200 (100 men and 100 women) participants completely responded to the questionnaire with a response rate of approximately 85%. The mean age of participants was 30.93 ± 5.56 years. In terms of satisfaction with information provided about the cause of in- fertility, male responders reported the lowest mean score of 3.59 ± 1.05 compared to female responders (3.82 ± 0.85, P=0.078). Infertile women had a greater mean score of 3.85 ± 0.78 than infertile men (3.58 ± 1.29) in satisfaction with information provided about the type of recommended treatment (P=0.037). There was a statistically significant difference between males (3.26 ± 1.04) and females (3.58 ± 0.93) in satisfaction with approximate treatment duration (P=0.031).

Conclusion

According to the results, most infertile patients were satisfied with the informing process related to the cause of infertility and recommended therapies. Information about infertility should be provided more systemati- cally to all treated patients by medical staff, especially in terms of success rate of treatment and financial cost of therapy.

Who is the gate keeper for treatment in a fertility clinic in Germany? -baseline results of a prospective cohort study (PinK study)

BACKGROUND

It is estimated that 5-15% of all couples in industrialised nations are infertile. A perceived unfulfilled desire for a child or self-identification as infertile can lead to psychological strain and social isolation. About 53.000 women underwent assisted reproduction treatments in Germany in 2014. Little is known about the first medical consultation and patient needs prior to the first visit in a fertility clinic in Germany. The baseline survey of the prospective cohort study on couples undergoing fertility treatment in Germany (PinK Study) provides first results on this topic for Germany.

METHODS

The baseline survey was conducted between 2012 and 2013. Self-administered questionnaires were handed out to patients of six fertility clinics at the beginning of treatment by clinic staff. At a participation rate of 31.0%, we were able to analyse data on 323 women and 242 men.

RESULTS

92.6% of the women had their initial medical consultation on their unfulfilled desire for a child with a gynaecologist. After the urologist (44.2%), the general practitioner (12.0%) was the second most approached initial contact person for men. 36.4% of all men had no medical consultation on the unfulfilled desire for a child before visiting a fertility clinic. 46.9% of the respondents expressed the wish that the conversation about infertility should be initiated by a physician. Prior to their first visit to a fertility clinic, 11.2% of the men and 24.8% of the women were informed by a physician that infertility treatment can cause emotional strain.

CONCLUSION

While almost all women consult a gynaecologist prior to the first visit in a fertility centre, one out of three men do not consult any physician at that stage. For the remaining group of men, urologists and general practitioners are the most important contact persons. Gender-specific health care needs are evident. In order to close the health care gap for men in Germany, more opportunities for discreet access to consultation should be offered. Due to its low threshold and family-oriented approach, general practice could make an important contribution to this effect.

Imaginability of adoption, foster care, and life without a(nother) child and stress in women and men in fertility treatment

We study whether the imaginability of adoption, foster care, and life without a(nother) child protects from stress during fertility treatment. Data from a self-administered prospective cohort study of couples who had just started treatment were used (T1 = 441 respondents; T2 = 142 respondents). Most respondents cannot imagine alternatives to treatment. Adoption/foster care is preferred over life without children. Imaginability of alternatives is associated with lower fertility-related (T1) and treatment-related stress (T2). Experience of a pregnancy/birth does not moderate the association. Thus, the availability of alternatives to treatment turns out to be helpful in terms of self-regulation during fertility treatment.

Claims for fertility interventions: a systematic assessment of statements on UK fertility centre websites

OBJECTIVES

Fertility services in the UK are offered by over 200 Human Fertilisation and Embryology Authority (HFEA)-registered NHS and private clinics. While in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) form part of the National Institute for Health and Care Excellence (NICE) guidance, many further interventions are offered. We aimed to record claims of benefit for interventions offered by fertility centres via information on the centres' websites and record what evidence was cited for these claims.

METHODS

We obtained from HFEA a list of all UK centres providing fertility treatments and examined their websites. We listed fertility interventions offered in addition to standard IVF and ICSI and recorded statements about interventions that claimed or implied improvements in fertility in healthy women. We recorded which claims were quantified, and the evidence cited in support of the claims. Two reviewers extracted data from websites. We accessed websites from 21 December 2015 to 31 March 2016.

RESULTS

We found 233 websites for HFEA-registered fertility treatment centres, of which 152 (65%) were excluded as duplicates or satellite centres, 2 were andrology clinics and 5 were unavailable or under construction websites. In total, 74 fertility centre websites, incorporating 1401 web pages, were examined for claims. We found 276 claims of benefit relating to 41 different fertility interventions made by 60 of the 74 centres (median 3 per website; range 0 to 10). Quantification was given for 79 (29%) of the claims. 16 published references were cited 21 times on 13 of the 74 websites.

CONCLUSIONS

Many fertility centres in the UK offer a range of treatments in addition to standard IVF procedures, and for many of these interventions claims of benefit are made. In most cases, the claims are not quantified and evidence is not cited to support the claims. There is a need for more information on interventions to be made available by fertility centres, to support well-informed treatment decisions.

A longitudinal study investigating the role of decisional conflicts and regret and short-term psychological adjustment after IVF treatment failure

STUDY QUESTION

What is the relationship between decisional conflict, decisional regret and psychological well-being in women following unsuccessful IVF cycles?

SUMMARY ANSWER

The mediating effect of decisional regret on the relationship between decisional conflict and fertility-related quality of life (FRQOL) has been found to be moderated by the availability (versus absence) of frozen embryos after an unsuccessful IVF cycle.

WHAT IS KNOWN ALREADY

Infertility treatment is marked by its open-ended nature. Stresses in treatment decision-making could be aggravated by a culture which honours families through procreation. While studies have investigated treatment-related decision-making among infertile women, little is known about the mental health consequences of decisional conflict and decisional regret following an unsuccessful IVF cycle.

STUDY DESIGN, SIZE, DURATION

A study was conducted over a 3-month period with infertile women who had recently experienced a failed IVF cycle (T₀). Decisional conflict when they decided on terminating or continuing treatment (T₁) and decisional regret 3 months later (T₂) were measured. Participants reported their levels of depression, anxiety and FRQOL at three time points. A total of 151 participants completed all time points (attrition rate: 39%). The average age of participants was 37.2 years, and they had had 1.1 cycles (range: 0-8) on average at the time of study intake. The duration of the study was 2 years.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were infertile women who were not pregnant following an IVF cycle recruited from a university-affiliated assisted reproduction centre. Following the notification of a negative pregnancy result, patients were invited to complete measures of FRQOL, depression and anxiety across three time points and decisional conflict and decisional regret at T₁ and T₂ respectively.

MAIN RESULTS AND THE ROLE OF CHANCE

Decisional regret partially mediated the effect of decisional conflict on overall and treatment-specific FRQOL (P < 0.05). The mediation by decisional regret was present only among participants who had no remaining frozen embryos after their unsuccessful IVF cycle (P < 0.05).

LIMITATIONS, REASON FOR CAUTION

Self-selection bias at recruitment remains a concern.

WIDER IMPLICATIONS OF THE FINDINGS

Our results show for the first time how mental health implications of decisional conflict may vary among patients with different clinical characteristics (i.e. availability of frozen embryos), despite their common experience of an unsuccessful IVF cycle. Healthcare professionals should be aware of the psychological ramifications of treatment decision-making difficulties, as well as individual differences in adjustment to unsuccessful treatment.

STUDY FUNDING/COMPETING INTERESTS

The study was funded by the Hong Kong University Grant Council-General Research Fund (HKU740613) and the authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

HKU Clinical Trials Registry (Trial registration number: HKUCTR-1680).

Patient centred care in infertility health care: direct and indirect associations with wellbeing during treatment

OBJECTIVE

To investigate whether different dimensions of patient centred care (PCC) were directly associated with wellbeing or indirectly, via lower concerns about medical procedures and/or increased tolerability of treatment.

METHODS

Cross-sectional study with 322 women and 111 men undergoing fertility diagnosis or treatment recruited online and in clinical setting. Participants completed questionnaires that assess PCC (PCQ-Infertility), individual (BSI Anxiety and Depression subscales) and relational wellbeing (FertiQoL Relational Domain), treatment concerns (CART Procedural Concerns scale) and tolerability (FertiQoL Tolerability Domain) and they filled a socio-demographic and fertility data file.

RESULTS

All dimensions of PCC were positively associated with better wellbeing except for organization of care. Information provision and continuity of care were indirectly associated with better individual wellbeing, the first via lower treatment concerns and the second via higher treatment tolerability. Competence, accessibility, continuity and communication were indirectly associated with better relational wellbeing via higher treatment tolerability.

CONCLUSIONS

Patient centred care promotes wellbeing during treatment. PCC is directly associated to wellbeing but also indirectly. The mode of action of the different PCC dimensions on wellbeing varies.

PRACTICAL IMPLICATIONS

To promote patients' wellbeing during treatment clinics should provide treatment related information and allow patients to establish a stable clinical relationship with a trustworthy and competent physician.

[Preimplantation and prenatal counseling. Interdisciplinary and multiprofessional approach]

Several new legal regulations and guidelines introduced in 2010 have changed the duties involved in medical information and counseling on preimplantation genetics (PGD) and prenatal diagnosis (PND).These regulations share the goal of a high-quality health service offering patients interdisciplinary and multidisciplinary expertise, especially taking into account psychological and social aspects. This contribution presents crucial elements for cooperating counseling in the PGD and PND fields. It considers results from a nationwide survey of all professional groups involved in counseling after a pathological prenatal diagnosis according to the law. Crucial to interdisciplinary counseling are choosing the appropriate medical specialty for referral, a positive basis for cooperation, and the right time for consulting another doctor. Several central issues have been identified for successful multidisciplinary counseling: identifying the suitable moment and method to establish contact between the patient and psychosocial counselor, focusing on PGD and PND centers as well as on the transparent qualifications of psychosocial counselors, and appreciating the importance of cooperation.

What do you know about reproductive medicine?--results of a German representative survey

OBJECTIVE

The use of reproductive medical treatments has become increasingly routine in recent years. This paper reports on a study of how different aspects of modern reproductive medicine are perceived by the German population.

DESIGN

Findings from a nationally representative sample of 2110 men and women aged 18 to 50 are presented. Participants responded to a questionnaire seeking self-report information about attitudes and knowledge regarding different aspects of reproductive medicine.

RESULTS

The majority of respondents had already heard or read something about reproductive medicine; knowledge gaps were prevalent in men and individuals with lower levels of education. The decrease in female fertility usually was underestimated, whereas both the number of involuntarily childless couples and the success rate of reproductive medical treatment were overestimated. One-third of participants would make use of reproductive medicine to have their own child.

CONCLUSION

This study revealed inadequacies in the knowledge of the German general population regarding reproductive medicine. Despite the low interest and poor knowledge of the topic, a broad acceptance of reproductive medical methods was reported. The results illustrate the need for adequate information transfer regarding female fertility as well as success rate and risks of reproductive medical interventions.

Why we should talk about compliance with assisted reproductive technologies (ART): a systematic review and meta-analysis of ART compliance rates

BACKGROUND

The goal of this systematic review and meta-analysis was to estimate the rate of compliance with assisted reproductive technologies (ART) and examine its relationship with treatment success rates.

METHODS

Six databases were systematically searched from 1978 to December 2011. Studies were included if they reported data on patient progression through three consecutive standard ART cycles. Compliance was estimated for the first three ART cycles (typical ART Regimen Compliance, TARC) and after the first and the second failed cycles (CAF1, CAF2). Treatment success rates for all patients who started ART and for those who fully complied with the three ART cycles were estimated.

RESULTS

Ten studies with data for 14 810 patients were included. TARC was 78.2% [95% confidence interval (CI) 68.8-85.3%], CAF1 was 81.8% (73.3-88.1%) and CAF2 was 75.3% (68.2-81.2%). The overall success rate was 42.7% (32.6-53.6%) for all patients starting ART and 57.9% (49.4-65.9%) for those who complied with three ART cycles. Compliance rates did not vary according to study quality, but TARC was higher for studies that reported data on doctor-censored patients versus those that did not (84.2% 95% CI 75.5-90.2 versus 70.6% 95% CI 58.3-80.5, P = 0.043). Analysis of funnel plots and the Egger test indicated publication bias for CAF1.

CONCLUSIONS

Findings from this meta-analysis should reassure clinics and patients that most patients are able to comply with three cycles of ART. Compliers could increase their chances of success by as much as 15%. A more detailed assessment of compliance requires monitoring long-term treatment trajectories through the creation of national registries.

Why we should talk about compliance with assisted reproductive technologies (ART): a systematic review and meta-analysis of ART compliance rates

BACKGROUND

The goal of this systematic review and meta-analysis was to estimate the rate of compliance with assisted reproductive technologies (ART) and examine its relationship with treatment success rates.

METHODS

Six databases were systematically searched from 1978 to December 2011. Studies were included if they reported data on patient progression through three consecutive standard ART cycles. Compliance was estimated for the first three ART cycles (typical ART Regimen Compliance, TARC) and after the first and the second failed cycles (CAF1, CAF2). Treatment success rates for all patients who started ART and for those who fully complied with the three ART cycles were estimated.

RESULTS

Ten studies with data for 14 810 patients were included. TARC was 78.2% [95% confidence interval (CI) 68.8-85.3%], CAF1 was 81.8% (73.3-88.1%) and CAF2 was 75.3% (68.2-81.2%). The overall success rate was 42.7% (32.6-53.6%) for all patients starting ART and 57.9% (49.4-65.9%) for those who complied with three ART cycles. Compliance rates did not vary according to study quality, but TARC was higher for studies that reported data on doctor-censored patients versus those that did not (84.2% 95% CI 75.5-90.2 versus 70.6% 95% CI 58.3-80.5, P = 0.043). Analysis of funnel plots and the Egger test indicated publication bias for CAF1.

CONCLUSIONS

Findings from this meta-analysis should reassure clinics and patients that most patients are able to comply with three cycles of ART. Compliers could increase their chances of success by as much as 15%. A more detailed assessment of compliance requires monitoring long-term treatment trajectories through the creation of national registries.

Eggs, ethics and exploitation? Investigating women's experiences of an egg sharing scheme

There is a growing global demand for human eggs for the treatment of sub-fertile women and for stem cell-related research. This demand provokes concerns for the women providing the eggs, including their possible exploitation, whether they should be paid, whether they can give properly informed consent and whether their eggs and bodies are becoming commodified. However, few of the debates have benefitted from insights from the women themselves. We address this gap in knowledge by reporting on a study investigating women's views and experiences of a scheme in which they can volunteer, in their capacity as fertility patients, to 'share' their eggs with researchers and receive a reduction in in vitro fertilisation fees. We focus our discussion on the question of exploitation, a concept central to many sociological and ethical interests. In brief, our analysis suggests that while interviewees acknowledge the potential of this scheme to be exploitative, they argue that this is not the case, emphasising their ability to act autonomously in deciding to volunteer. Nonetheless, these freely made decisions do not necessarily take place under circumstances of their choosing. We discuss the implications of this for egg provision in general and for understandings of exploitation.

[The physician's role in various clinical contexts. Physician counseling on in vitro fertilization (IVF) and preimplantation genetic diagnosis (PGD)]

The role of the physician in the context of in vitro fertilization and preimplantation genetic diagnosis has certain distinct characteristics. Involuntary childlessness by definition of the WHO is a disease with good treatment options. As it is not considered a medical emergency, the focus lies more on intensive information giving, education, and counseling. Because the diagnosis and treatment can be a medical and psychological strain for the couple, counseling should address both medical and psychological aspects. The physician needs to have detailed medical knowledge as well as good communication skills to be able to meet the specific needs of the couple. Moreover, the physician should point out the realistic success rates of treatment and should refer to alternatives, such as remaining childless, adoption, and sperm or egg donation. The concurrent inclusion of biological, psychological, social, and ethical aspects in terms of psychosomatic basic care (Psychosomatische Grundversorgung) seems to be useful. There is potential for conflicts, for example, due to the economic interests of the physician. On the other hand, the treatment can be a financial burden for the couple. Of importance are the physician's and the patient's moral concepts, especially concerning some aspects of therapy (sperm and egg donation, surrogacy). The expected welfare of the intended child should also be respected (e.g., higher risk of preterm birth in multiple pregnancies). Further possible conflicts in reproductive medicine arise because of the crossing of moral boundaries (oocyte donation for postmenopausal women, surrogacy, cloning of human beings). The framework of counseling is based on the guidelines of the German Medical Association (Bundesärztekammer) for assisted reproduction (2006). Preimplantation genetic diagnosis has special requirements from a medical and psychosocial point of view.