Infertility & assisted reproduction: A historical & modern scientific perspective

A comprehensive review on potential role of selenium, selenoproteins and selenium nanoparticles in male fertility

Selenium (Se), a component of selenoproteins and selenocompounds in the human body, is crucial for the development of male reproductive organs, DNA synthesis, thyroid hormone, metabolism, and defence against infections and oxidative damage. In the testis, it must exceed a desirable level since either a shortage or an overabundance causes aberrant growth. The antioxidant properties of selenium are essential for preserving human reproductive health. Selenoproteins, which have important structural and enzymatic properties, control the biological activities of Se primarily. These proteins specifically have a role in metabolism and a variety of cellular processes, such as the control of selenium transport, thyroid hormone metabolism, immunity, and redox balance. Selenium nanoparticles (SeNPs) are less hazardous than selenium-based inorganic and organic materials. Upon being functionalized with active targeting ligands, they are both biocompatible and capable of efficiently delivering combinations of payloads to particular cells. In this review, we discuss briefly the chemistry, structure and functions of selenium and milestones of selenium and selenoproteins. Next we discuss the various factors influences male infertility, biological functions of selenium and selenoproteins, and role of selenium and selenoproteins in spermatogenesis and male fertility. Furthermore, we discuss the molecular mechanism of selenium transport and protective effects of selenium on oxidative stress, apoptosis and inflammation. We also highlight critical contribution of selenium nanoparticles on male fertility and spermatogenesis. Finally ends with conclusion and future perspectives.

Predictive Role of Progesterone Levels for IVF Outcome in Different Phases of Controlled Ovarian Stimulation for Patients With and Without Endometriosis: Expert View

The study aimed to review the role of basal, trigger, and aspiration day progesterone levels (PLs) as predictors of in vitro fertilization (IVF) success for patients with and without endometriosis. A non-systematic review was conducted by searching papers published in English during the period of 1990-2023 in MEDLINE and PubMed, Embase, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), and Web of Science. The most widely used IVF predictor success was the trigger day progesterone serum level. Many studies utilize the threshold level of 1.5-2.0 ng/ml. However, the predictive power of only progesterone level failed to show high sensitivity and specificity. Contrary, progesterone level on the trigger day combined with the number of mature retrieved oocytes had the highest predictive power. High baseline progesterone level was associated with poor IVF outcomes. Research on progesterone and IVF success in patients with endometriosis is limited but indicates that endometriosis patients seem to benefit from higher progesterone concentrations (≥ 37.1 ng/ml) in IVF cycles. Currently, there is limited data for a definitive insight into the mportance of progesterone in the estimation of IVF success. Nonetheless, this summarized evidence could serve as up-to-date guidance for the role of progesterone in the prediction of IVF outcomes, both in patients with and without endometriosis.

Deprived areas and adverse perinatal outcome: a systematic review

PURPOSE

This systematic review aimed to assess if women living in deprived areas have worse perinatal outcomes than those residing in high-income areas.

METHODS

Datasets of PubMed, ScienceDirect, CENTRAL, Embase, and Google Scholar were searched for studies comparing perinatal outcomes (preterm birth, small-for-gestational age, and stillbirth) in deprived and non-deprive areas.

RESULTS

A total of 46 studies were included. The systematic review of the literature revealed a higher risk for adverse perinatal outcomes such as preterm birth, small for gestational age, and stillbirth in deprived areas.

CONCLUSION

Deprived areas are associated with adverse perinatal outcomes. More multifactorial studies are needed to assess the weight of each factor that composes the socioeconomic gradient of health in adverse perinatal outcomes.

Obstetric and Neonatal Outcomes After Transferring More Than One Embryo in Patients With Preimplantation Genetic Testing

OBJECTIVE

To compare obstetric and neonatal outcomes after single embryo transfer (SET) compared with multiple embryo transfer (MET) from frozen-thawed transfer cycles of embryos that underwent preimplantation genetic testing for aneuploidies (PGT-A).

METHODS

We conducted a retrospective cohort study from the SART CORS (Society for Assisted Reproductive Technology Clinic Outcome Reporting System) national database. Clinical and demographic data were obtained from the SART CORS database for all autologous and donor egg frozen-thawed transfer cycles of embryos that underwent PGT-A between 2014 and 2016, after excluding cycles that used frozen oocytes, fresh embryo transfer, and transfers of embryos from more than one stimulation cycle. Multivariable linear and log-binomial regression models were used to estimate the relative and absolute difference in live-birth rate, multiple pregnancy rate, gestational age at delivery, and birth weight between SET compared with MET.

RESULTS

In total, 15,638 autologous egg transfer cycles and 944 donor egg transfer cycles were analyzed. Although the live-birth rate was higher with MET compared with SET in the autologous oocyte cycles (64.7% vs 53.2%, relative risk [RR] 1.24, 95% CI, 1.20-1.28), the multiple pregnancy rate was markedly greater (46.2% vs 1.4%, RR 32.56, 95% CI, 26.55-39.92). Donor oocyte cycles showed similar trends with an increased live-birth rate (62.0% vs 49.7%, RR 1.26, 95% CI, 1.11-1.46) and multiple pregnancy rate (54.0% vs 0.8%) seen with MET compared with SET. Preterm delivery rates and rates of low birth weight were significantly higher in MET compared with SET in both autologous and donor oocyte cycles and were also higher in the subanalysis of singleton deliveries that resulted from MET compared with SET.

CONCLUSION

Despite some improvement in live-birth rate, nearly half of the pregnancies that resulted from MET of embryos that underwent PGT-A were multiples. Compared with SET, MET is associated with significantly higher rates of neonatal morbidity, including preterm delivery and low birth weight. The transfer of more than one embryo that underwent PGT-A should continue to be strongly discouraged, and patients should be counseled on the significant potential for adverse outcomes.

The impact of transferred air bubble position on clinical pregnancy rate in FET cycles

We aim to investigate the correlation of the position of the transferred air bubble with the clinical pregnancy rate (PR) in frozen-thawed embryo transfer(FET) cycles. A prospective clinical study was carried out at Reproductive medicine center of West China Second University Hospital between June 2020 and May 2021. 1159 women underwent FET were included in this study. Transabdominal ultrasonographic guidance was used during the transfer procedure. The distance from the air bubble to endometrial cavity fundus（DAF）was measured in the freeze-frame ultrasound immediately after ET. In group DAF ≤3mm, 3-15mm and ≥15mm, the clinical PR in women transferred with cleavage embryos were 33.3% (7/21), 55.0% (153/280), and 31.3% (5/16), respectively, the difference was statistically significant (P＜0.05). Among women transferred with blastocysts, the clinical PR was 63.0% (34/54), 68.5% (485/708) and 55.0% (44/80), respectively, the difference was statistically significant (P＜0.05). In multivariate logistic regression model for clinical PR, the clinical PR was associated with age, embryo quality, number of embryo transferred, and endometrial thickness. DAF was an independent risk factor influencing clinical PR in blastocysts FET cycles rather than in cleavage embryos FET cycles.In conclusion, our results suggested that DAF was associated with the clinical PR and DAF between 3mm and 15mm is the optimal position in blastocysts FET cycles.

Association Between Endometriosis and Mental Disorders Including Psychiatric Disorders, Suicide, and All-Cause Mortality -A Nationwide Population-Based Cohort Study in Taiwan

Objective

A multitude of previous studies has substantiated that endometriosis correlated highly with psychiatric health. This study aims to investigate the association between endometriosis and psychiatric health.

Methods

Utilizing the National Health Insurance Research Database of Taiwan, 100,770 enrolled participants, including 20,154 patients with endometriosis and 80,616 in the control group (1:4), matched for age, and index date from Taiwan's Longitudinal Health Insurance Database between January 1, 2000, and December 31, 2015. The Cox proportional regression model was used to compare the risk of mental disorders during the 16 years of follow-up after adjusting for confounding factors.

Results

Of the study patients, 4083 (20.26%) developed mental disorders; 9225 of the 80,616 controls (11.44%) developed mental disorders. The Cox regression demonstrated that, after adjusting for age, monthly income, urbanization level, etc., people with endometriosis are more likely to suffer from mental disorders compared to those without endometriosis (hazard ratio [HR]=2.131; 95% confidence interval [CI]= 1.531-2.788; p<0.001). The result illustrated that women over 40 years old had a more significant risk.

Conclusion

Compared to people without endometriosis, this study provides evidence that patients with endometriosis are at a 2.131-fold higher risk of developing mental disorders, especially in elder women. Regular psychiatric follow-up might be needed for those patients.

The optimal route of progesterone administration for luteal phase support in a frozen embryo transfer: a systematic review

OBJECTIVE

To investigate the optimal route of progesterone administration for luteal phase support in a frozen embryo transfer.

DESIGN

Systematic review.

PATIENTS

Women undergoing frozen embryo transfer (FET).

INTERVENTIONS

We conducted an extensive database search of Medline (PubMed), Embase, Web of Science, and Cochrane Trials Register using relevant keywords and their combinations to find randomized controlled trials (RCTs) comparing the routes (i.e., oral, vaginal, intramuscular) of progesterone administration for luteal phase support (LPS) in artificial FET.

MAIN OUTCOME MEASURES

Clinical pregnancy, live birth, miscarriage.

RESULTS

Four RCTs with 3245 participants undergoing artificial endometrial preparation (EP) cycles during FET were found to be eligible. Four trials compared vaginal progesterone with intramuscular progesterone and two trials compared vaginal progesterone with oral progesterone. One study favored of vaginal versus oral progesterone for clinical pregnancy rates (RR 0.45, 95% CI 0.22-0.92) and other study favored intramuscular versus vaginal progesterone for clinical pregnancy rates (RR 1.46, 95% CI 1.21-1.76) and live birth rates (RR 1.62, 95% CI 1.28-2.05). Tabulation of overall evidence strength assessment showed low-quality evidence on the basis that for each outcome-comparison pair, there were deficiencies in either directness of outcome measurement or study quality.

CONCLUSION

There was little consensus and evidence was heterogeneous on the optimal route of administration of progesterone for LPS during FET in artificial EP cycles. This warrants more trials, indirect comparisons, and network meta-analyses.

PROPERO NO

CRD42021251017.

The advantages and disadvantages of altruistic and commercial surrogacy in India

BACKGROUND

Comprehensive commercial surrogacy became legal in India in 2002, and many foreigners, including individuals and same-sex couples, sought Indian surrogacy services due to their affordability. Numerous scandals resulted, with increasing calls for the government to eliminate the exploitation of women in lower social strata. In 2015, the Indian government decided to exclude foreign clients and commercial surrogacy remained legal for local Indian couples only. Furthermore, to eliminate exploitation, the concept of altruistic surrogacy was introduced in 2016. In 2020, some restrictions within altruistic surrogacy practice were removed. Controversy remains, however, in various sectors, not least because surrogacy is a relatively new concept in India. In this paper, the advantages and disadvantages of both altruistic and commercial surrogacy in the Indian context are considered, and more appropriate policy concerning surrogacy practices is suggested.

METHODS

This paper is based on fieldwork conducted in India from 2010 to 2018. Interview surveys were conducted among doctors, policy makers, activists, former surrogates, and brokers. Government documents and media reports were also important sources.

RESULTS

Surrogacy for commercial purposes began in India in 2002, and stakeholders within the commercial surrogacy industry became well established. It was found that such stakeholders were strongly opposed to altruistic surrogacy as introduced in 2016. It was also found that women in lower social strata still sought some form of financial compensation from their reproductive labor. Controversies surrounding altruistic surrogacy continue within Indian society.

CONCLUSION

Policies and practices aimed at eliminating exploitive need to consider the Indian context carefully. Any surrogacy practice might potentially be exploitive, and the distinction between commercial and altruistic surrogacy is too simplistic to be useful, with more nuanced understanding required. It is of critical importance that investigation continues on how to eliminate the exploitation of Indian surrogate mothers throughout the process, regardless of monetary compensation. The entire surrogacy process should be managed with sensitivity, particularly in relation to the well-being of the mother and child.

Determinants of very low birth weight in India: The National Family Health Survey – 4

Background

Low birth weight (LBW) is susceptible to neonatal complications, chronic medical conditions, and neurodevelopmental disabilities. We aim to describe the determinants of very low birth weight (VLBW) in India and compare it with the determinants of LBW based on the National Family Health Survey – 4 (NHFS-4)

Methods

Data from the NFHS-4 on birthweight and other socio-demographic characteristics for the youngest child born in the family during the five years preceding the survey were used. Data of 147,762 infant–mother pairs were included. Multiple logistic regression models were employed to delineate the independent predictors of VLBW (birth weight<1500 g) or LBW  (birth weight: 1500-2499 g).

Results

Of the 147,762 children included in the study, VLBW and LBW were observed in 1.2% and 15.8% of children, respectively. The odds of VLBW were higher in female children (aOR: 1.36, 95% CI: 1.15–1.60), among mothers aged 13–19 years (aOR: 1.58, 95% CI: 1.22–2.07), mothers with severe or moderate anaemia (aOR: 1.61, 95% CI: 1.34–1.94), mothers without recommended antenatal care (aOR: 1.47, 95% CI: 1.31–1.90), maternal height less than 150 cm (aOR: 1.54, 95% CI: 1.29–1.85) and among mothers with multiple pregnancy (aOR: 21.34, 95% CI: 14.70–30.96) in comparison to their corresponding counterparts. In addition to the variables associated with VLBW, educational status of mothers (no education; aOR: 1.08, 95% CI: 1.02–1.15 and primary education; aOR: 1.16, 95% CI: 1.08–1.25), caste of the children (scheduled tribe; aOR: 1.13, 95% CI: 1.03–1.24), and wealthiness of the family (poorest wealth quintiles; aOR: 1.11, 95% CI: 1.03–1.19) were associated with LBW.

Conclusions

Interventions targeting improvements in antenatal care access, maternal health, and nutritional status may reduce the number of VLBW infants. Social determinants of LBW require further detailed study to understand the high propensity of low birth-weight phenotypes in the disadvantaged communities in India.

Determinants of very low birth weight in India: The National Family Health Survey – 4

Background Low birth weight (LBW) is susceptible to neonatal complications, chronic medical conditions, and neurodevelopmental disabilities. We aim to describe the determinants of very low birth weight (VLBW) in India based on the National Family Health Survey – 4 (NHFS-4). Methods Data from the NFHS 4 on birthweight and other socio-demographic characteristics for the youngest child born in the family during the five years preceding the survey were used. Data of 147,762 infant–mother pairs were included. Multiple logistic regression models were employed to delineate the independent predictors of VLBW (birth weight<1500 g) or LBW (birth weight <2500 g). Results Of the 147,762 children included in the study, VLBW and LBW were observed in 1.2% and 15.8% of children, respectively. The odds of VLBW were higher in female children (aOR: 1.36, 95% CI: 1.15–1.60), among mothers aged 13–19 years (aOR: 1.58, 95% CI: 1.22–2.07), mothers with severe or moderate anaemia (aOR: 1.61, 95% CI: 1.34–1.94), mothers without recommended antenatal care (aOR: 1.47, 95% CI: 1.31–1.90), maternal height less than 150 cm (aOR: 1.54, 95% CI: 1.29–1.85) and among mothers with multiple pregnancy (aOR: 21.34, 95% CI: 14.70–30.96) in comparison to their corresponding counterparts. In addition to the variables associated with VLBW, educational status of mothers (no education; aOR: 1.08, 95% CI: 1.02–1.15 and primary education; aOR: 1.16, 95% CI: 1.08–1.25), caste of the children (scheduled tribe; aOR: 1.13, 95% CI: 1.03–1.24), and wealthiness of the family (poorest wealth quintiles; aOR: 1.11, 95% CI: 1.03–1.19) were associated with LBW. Conclusions Interventions targeting improvements in antenatal care access, maternal health, and nutritional status may reduce the number of VLBW infants. Social determinants of LBW require further detailed study to understand the high propensity of low birth-weight phenotypes in the disadvantaged communities in India.

Comparison of outcomes of monochorionic twin pregnancies conceived by assisted reproductive technology vs. spontaneous conceptions: A systematic review and meta-analysis

BACKGROUND

This review aimed to assess if monochorionic twin pregnancies conceived by assisted conception have worse maternal and neonatal outcomes as compared to those conceived naturally.

METHODS

Datasets of PubMed, ScienceDirect, CENTRAL, Embase, and Google Scholar were searched for studies comparing maternal and neonatal outcomes of monochorionic twin pregnancies conceived by assisted vs. spontaneous methods.

RESULTS

Eight studies comparing 337 assisted with 2,711 spontaneously conceived monochorionic twin pregnancies were included. Meta-analysis revealed that the mode of conception of monochorionic twin pregnancies had no impact on the risk of hypertensive disorders of pregnancy (HDP) (OR: 1.36 95% CI, 0.73, 2.54 I ² = 9% p = 0.03), twin-twin transfusion syndrome (TTTS) (OR: 0.83 95% CI, 0.52, 1.31 I ² = 0% p = 0.42), and very preterm delivery (OR: 1.18 95% CI, 0.74, 1.88 I ² = 41% p = 0.49). We noted no statistically significant difference in the mean birth weights (MD: -17.66 95% CI, -157.23, 121.91 I ² = 82% p = 0.80), risk of intra-uterine death (OR: 0.90 95% CI, 0.51, 1.60 I ² = 36% p = 0.73) and small for gestational age between the two groups (OR: 0.92 95% CI, 0.67, 1.26 I ² = 0% p = 0.59). There was an increased risk of caesarean sections (OR: 1.34 95% CI, 1.00, 1.80 I ² = 0% p = 0.05) and neonatal death with assisted conceptions as compared to spontaneous conceptions (OR: 2.35 95% CI, 1.11, 5.01 I ² = 37% p = 0.03).

CONCLUSION

Monochorionic twin pregnancies conceived via assisted reproductive technology have a heightened risk of cesarean section and neonatal deaths. However, there is a need for further studies to supplement current evidence.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=325133, identifier: CRD42022325133.

ISAR Consensus Guidelines on Safety and Ethical Practices in In vitro Fertilization Clinics

STUDY QUESTION

What are the Safe and Ethical practices for ART applicable in INDIA?

WHAT IS ALREADY KNOWN

The Indian IVF industry is booming; with mushrooming of assisted reproductive technology (ART) clinics in the country, the need for regulation is immense. The ISAR has taken up this initiative to lead the way forward in establishing practice guidelines for the safe and ethical use of ARTs in our country. These guidelines discuss the points to consider before the starting of an IVF unit, to the designing of the laboratory, the staffing pattern and experience recommendations, laboratory safety guidelines, documentation and patient traceability, gamete traceability, handling biological material, the consumables and media, and different consents and checklists and also propose key performance indicators for the Indian scenario.

STUDY DESIGN SIZE DURATION

This is the report of a 2-day consensus meeting where two moderators were assigned to a group of experts to collate information on safe and ethical ivf practices in INDIA. This meeting utilised surveys, available scientific evidence and personal laboratory experience into various presentations by experts on pre-decided specific topics.

PARTICIPANTS/MATERIALS SETTING METHODS

Expert professionals from ISAR representing clinical and embryology fields.

MAIN RESULTS AND THE ROLE OF CHANCE

The report is divided in various components including the regulations, the various requirements for an ART center, qualifications and trainings, recommendations on good practices and quality management: the report and recommendations of the expert panel reflect the discussion on each of the topics and try to lay down good practice points for labs to follow.

LIMITATIONS REASONS FOR CAUTION

The recommendations are solely based on expert opinion. Future availability of data may warrant an update of the same.

WIDER IMPLICATIONS OF THE FINDINGS

These guidelines can help labs across the country to standardise their ART services and improve clinical outcomes.

STUDY FUNDING/COMPETING INTERESTS

The consensus meeting and writing of the paper was supported by funds from CooperSurgical India.

Risk factors of pregnancy failure in elderly infertility patients undergoing human assisted reproductive technology

OBJECTIVE

To investigate the risk factors of pregnancy failure in elderly infertile patients undergoing human assisted reproductive technology (ART).

METHODS

A total of 565 infertile patients undergoing ART were selected and divided into failed pregnancy group (127 cases) and continued pregnancy group (438 cases). Their clinical data were collected, and the influencing factors of pregnancy failure were assessed and compared by univariate and multivariate analysis.

RESULTS

The success and failure rates of in vitro fertilization-embryo transfer (IVF-ET) in pregnant women were 79.44% and 20.56%, while those of intracytoplasmic sperm injection (ICSI) were 75.96% and 24.04%, respectively. There was no remarkable difference between them (all P>0.05). Women's age, numbers of embryos transferred and previous abortion history in the failed pregnancy group were higher than those in the continued pregnancy group, while the number of high-quality embryos, BMI and endometrial thickness (EMT) on human chorionic gonadotropin (hCG) day in the former were lower (all P<0.05).

CONCLUSION

The risk factors of ART pregnancy failure in elderly infertility patients are related to woman's age, numbers of embryos transferred, previous pregnancy abortion history, numbers of high-quality embryos and EMT on hCG day.

Evidenced-based practice of decision-making process in oncofertility care among registered nurses: A qualitative study

AIM

The purpose of our study was to construct the context of the nursing action/role in oncofertility care.

DESIGN

Qualitative research.

METHODS

We applied grounded theory to guide the qualitative study. Data were collected through in-depth interviews with 12 nurses in Taipei. The data were collected from August 2018 to February 2019.

RESULTS

The core theme that described the role of nurses' decision-making in oncofertility care focused on understanding oncofertility from the self to the other. Care roles or actions in oncofertility that involved the process of psychological cognition were divided into four dimensions: perceiving the patient's changes and needs, triggering the self's emotions, empathizing with patient's situations and introspective care roles. Nurses who had experienced the phase of empathizing with the patient's situations developed more diverse roles and had positive actions toward oncofertility care. Based on the psychological changes for oncofertility decision-making process, implementing contextual training in oncofertility could help nurses create more positive actions in oncofertility care.

Economic costs of infertility care for patients in low-income and middle-income countries: a systematic review protocol

INTRODUCTION

Infertility, a condition of the reproductive system, affects millions of individuals and couples worldwide. Despite infertility treatment's existence, it is largely unavailable and inaccessible in low/middle-income countries (LMICs) due to the prohibitive costs compounded by an absence of financing. Previous systematic reviews have shown that there is scanty information in LMICs on out-of-pocket (OOP) payments for infertility treatment. This protocol outlines the methodological approach and analytical process to appraise the extent of economic burden due to payments for infertility care services in LMICs.

METHOD AND ANALYSIS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach, we will primarily search for articles indexed in PubMed, Web of Science, Cumulative Index of Nursing and Allied Health Literature, EconLit and PsycINFO databases. Grey literature from relevant organisations' virtual libraries shall also be searched. Backward and forward searches on the articles selected will also be done. Quantitative studies on infertility treatment costs from LMICs across the world regions within the last 20 years will be considered. The primary outcome of interest shall include OOP payments, catastrophic health expenditure and direct costs for infertility services. Conversely, informal payments and indirect costs related to infertility treatments shall be considered as secondary outcomes. Integrated quality Criteria for Review Of Multiple Study designs will be used to assess the quality of the studies included in the review. Meta-analysis shall be considered if sufficient studies identified are homogenous in characteristics. Also, the review shall analyse the average cost of infertility treatment against the respective countries' economic indicators like gross domestic product per capita if data permit.

ETHICS AND DISSEMINATION

Research and ethics approval will not be required given this will be a review of published articles on the subject. The findings shall be disseminated through publication in a peer-reviewed journal and presentation to the WHO and its partners.

PROSPERO REGISTRATION NUMBER

CRD42020199312.

Iranian infertile couples' strategies to manage social interactions after unsuccessful treatment with assisted reproductive technologies

Many infertile couples feel vulnerable after failed treatment cycles and find insensitive remarks or inappropriate support distressing. They fear that the stress of failed treatment cycles may affect their marriage and lead to marriage breakdown. This study explored the strategies a sample of infertile couples used to manage social interactions after unsuccessful treatment with assisted reproductive technologies. A descriptive qualitative study was conducted with 34 participants including nine infertile couples, nine infertile women and two infertile men with primary infertility, two relatives, and three fertility clinic staff. The participants were selected through purposive sampling at an infertility centre in Iran, between 2016 and 2017. Data were collected using semi-structured face-to-face interviews and analysed by qualitative content analysis approach. Participants found some social interactions after failed assisted reproductive treatment cycles to be distressing and painful. They described tolerating painful emotions which cause them sadness and sorrow as well as feeling embarrassed. As a result, they found they needed to maintain their adopting concealment strategies with their families through not permitting speculation, selective disclosure, not giving details and hiding the truth. This study showed that social interactions following failed assisted reproductive cycles can be upsetting for infertile couples. Couples use different strategies to manage potentially distressing social interactions. Healthcare providers and psychologists may provide a space for safe social interactions in order to help couples to use appropriate strategies in these circumstances.