What is bad news in fertility care? A qualitative analysis of staff and patients' accounts of bad and challenging news in fertility care

STUDY QUESTION

What do fertility staff and patients think is bad news in fertility care?

SUMMARY ANSWER

Staff and patients agree bad news is any news that makes patients less likely to achieve parenthood spontaneously or access and do successful treatment, but their appraisals of how bad the news is are differently influenced by specific news features and the context of its delivery.

WHAT IS KNOWN ALREADY

Bad news is common in fertility care, but staff feel unprepared to share it and four in 10 patients react to it with unanticipated emotional or physical reactions. Research has paid much attention to how bad news should be shared, but considerably less to what news is perceived as bad, despite the fact this may dictate elements of its delivery.

STUDY DESIGN, SIZE, DURATION

Two cross-sectional, online, mixed-method surveys (active 7 January-16 July 2022) were distributed to fertility staff and patients across the UK and Europe.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Staff inclusion criteria were being a healthcare professional working in fertility care and having experience of sharing bad news at least once a month. Patients' inclusion criteria were being adults and having had a conversation in which staff shared or explained bad news concerning their fertility care within the last 2 months. Surveys were created in English using Qualtrics, reviewed by patients and healthcare professionals, and distributed via social media, Prolific, fertility organizations, and scientific societies. Patients were asked, regarding the last time bad news were shared with them, 'What was the bad news?' and 'What other news would you consider bad news in fertility care?'. Staff were asked to 'List the three most challenging topics of bad news you share with your patients'. Staff and patient data were separately thematically analysed to produce basic codes, organized into sub-themes and themes. Themes emerging from patients' and staff data were compared and synthesized into meta themes.

MAIN RESULTS AND THE ROLE OF CHANCE

Three hundred thirty-four staff accessed the survey, 286 consented, and 217 completed (65% completion rate). Three hundred forty-four patients accessed the survey, 304 consented, and 222 completed (64% completion rate). Eighty-five percent of participants were women, 62% resided in Europe, and 59% were in private care. Average staff age was 45.2 (SD = 12.0), 44% were embryologists or lab technicians, 40% were clinicians (doctors, consultants, or physicians), and 8% nurses or midwifes. Average patient age was 32.2 (SD = 6.4) and 54% had children. Staff answers originated 100 codes, 19 sub-themes and six themes. Patients' answers produced 196 codes, 34 sub-themes, and 7 themes. Staff and patient themes were integrated into three meta-themes reflecting main topics of bad news. These were Diagnosis and negative treatment events and outcomes, Inability to do (more) treatment, and Care and patient factors disrupting communication. Staff and patients agreed that some news features (uncertain, disruptive, definitive) made news more challenging but disagreed in relation to other features (e.g. unexpected/expected). Patient factors made bad news more challenging to staff (e.g. difficult emotions) and care factors made bad news more challenging to patients (e.g. disorganized care).

LIMITATIONS, REASONS FOR CAUTION

Participants were self-selected, and most were women from private European clinics. Questions differed for staff and patients, focused on subjective perceptions of news, and did not measure news impact.

WIDER IMPLICATIONS OF THE FINDINGS

The badness of fertility news is not only a product of the extent to which the news compromises parenthood goals but also of its features (timing, nature, number) and the context in which the news is delivered. Guidance on sharing bad news in fertility care needs to go beyond easing the process for patients to also consider staff experiences. Guidance may need to be tailored to news features and context.

STUDY FUNDING/COMPETING INTEREST(S)

Cardiff University funded the research. S.G., J.B., O'.H., and A.D. report funding from the Higher Education Funding Council for Wales and the European Society for Human Reproduction and Embryology (ESHRE) to develop fertiShare: a sharing bad news eLearning course for fertility care. fertiShare will be distributed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Licence (CC BY-NC-SA 4.0). No other conflicts are reported in relation to this work.

TRIAL REGISTRATION NUMBER

N/A.

P–764 Risks of oocyte donation for third-party donors: a systematic literature review

Study question

What are the risks of oocyte donation? Which risks should be prioritised in policies aiming to improve the protection of third-party oocyte donors?

Summary answer

The risks for third-party oocyte donors are of a diverse nature, including physical risks, psychological risks, iatrogenic risks, and social risks.

What is known already

Oocyte donation involves ovarian stimulation and oocyte pick-up, which represent burdensome procedures for the donor. In a recent evaluation of the EU legislation on blood, tissue and cells, the European Commission highlighted that oocyte donors are currently not adequately protected. For effective oocyte donor protection measures to be developed and implemented, it is important to understand the risks that oocyte donors are exposed to. To date, there is no comprehensive overview of the existing knowledge on the physical and psychosocial risks of oocyte donation.

Study design, size, duration

A systematic literature review of the publications on PubMed, CINAHL, PsycINFO and the Notify Library was carried out. The search was conducted in May 2020. All empirical studies, including case reports, that reported or investigated negative experiences of oocyte donors and/or negative consequences of the donation on the donors’ physical health, mental health, or other aspects of their lives were included. No restriction was made with regard to the year of publication.

Participants/materials, setting, methods

In total, 88 empirical studies conducted in oocyte donors were reviewed. All reported information on oocyte donor risks was extracted and summarised. The identified risks were clustered into categories according to common themes and analysed with regard to their frequency of occurrence, severity, and imputability to the donation. A prioritisation of risks was carried out based on these three criteria, classifying each risk as a “priority risk” or a “non-priority risk”.

Main results and the role of chance

Nineteen priority risks were identified across the following six categories: short-term physical risks, long-term physical risks, short-term psychological risks, long-term psychological risks, iatrogenic risks, and social risks. The most frequently reported priority risks were moderate to severe Ovarian Hyperstimulation Syndrome (OHSS) and having lasting worries or concerns about the donation. While the findings confirmed the relevance of certain immediate physical risks for oocyte donors, no cases of death or permanent physical damage as a direct consequence of the donation could be detected. The results showed that donating oocytes can profoundly impact the donors’ psychological well-being in the short-term and in the long-term. Furthermore, the donation can have a strong effect on the donor’s social and family life, for instance, through the risk of unintended pregnancy. Moreover, it was found that oocyte donors are at risk of experiencing mistreatment or inadequate care during the donation procedure. Most studies included in the review reported on short-term risks of the donation. There is a high degree of uncertainty about the long-term health effects of oocyte donation. Due to the scarcity of large observational studies, the conclusions are mostly based on small studies and case reports, which limits the strength of any conclusion.

Limitations, reasons for caution

The literature search was limited to common databases for published data. Grey literature was not searched. Due to the heterogeneous nature of the relevant publications, it is possible that the search strategy was not able to detect all eligible articles.

Wider implications of the findings: The findings emphasise the importance of implementing effective donor protection policies that address not only the physical, but also the psychological, social, and iatrogenic risks of oocyte donation. Moreover, the findings call for a systematic follow-up of oocyte donors to gain insight into the long-term consequences of the donation.

Trial registration number

Not applicable

Fibrinogen Milano II: A Congenital Dysfibrinogenaemia Associated with Juvenile Arterial and Venous Thrombosis

A congenitally abnormal fibrinogen was isolated from blood of a young man with deep-vein thrombosis. Two other affected members of his family had three episodes of severe arterial thrombosis. The fibrinogen showed a delayed clotting by thrombin, but a normal clotting by Arvin®, Reptilase®, and prothrom-bin-staphylocoagulase complex. Analysis of the fibrinopeptides A and B by High Performance Liquid Chromatography did not reveal an abnormal peptide structure. The rate of release of A and B peptides by thrombin was strongly delayed, whereas the rate of release of fibrinopeptide A by Arvin® appeared to be normal. The fibrin polymerization rate was normal. Interactions between the abnormal fibrinogen, platelets and the fibrinolytic system were also normal. Evidence is presented that the defective interaction between fibrinogen Milano II and thrombin is associated with a defective binding of thrombin to the fibrin moiety of the abnormal fibrinogen.

High Fibrinopeptide A (FPA) Levels in Acute Non-Lymphocytic Leukemia Are Reduced by Heparin Administration

Plasma levels of fibrinopeptide A (FPA) in 30 untreated patients with acute non-lymphocytic leukemia (ANLL) were significantly higher than in 30 healthy controls (p <0.001). Patients without laboratory signs of disseminated intravascular coagulation (DIC) had levels of FPA higher than controls (p <0.02) but markedly lower than patients with DIC (p <0.001). Five patients with M3 leukemia had a higher mean FPA level (p <0.02) and a lower peripheral blast cell count (p <0.05) than patients with other cytological subtypes of ANLL. When patients with M3 were excluded, a significant correlation was observed between the peripheral blast cell counts and the FPA levels (r = 0.66, p <0.001). FPA levels were similar with body temperature either above or below 38° C. After intravenous bolus of heparin FPA dropped to normal levels in 14 out of 17 patients who had high baseline values. These findings indicate that intravascular thrombin formation, which probably result from the expression of procoagulant activities of blast cells, is the main cause of high FPA in the majority of patients with acute non-lymphocytic leukemia.

Protein C Antigen Is Not an Acute Phase Reactant and Is often High in Ischemic Heart Disease and Diabetes

Protein C, an antithrombotic protein, was measured immunologically in 299 patients with clinical conditions associated with a high frequency of venous or arterial thromboembolism. The mean protein C antigen (PC: Ag) level was high for 48 patients with ischemic heart disease and, to a lesser extent, for 95 diabetics. In 28 patients with thrombotic strokes, 48 patients with proximal deep-vein thrombosis and in 80 patients with localized or metastatic tumors, mean PC: Ag was normal. Comparison of the pattern of changes of PC: Ag levels with those of fibrinogen, orosomucoid and prothrombin in 21 patients during the postoperative period and in 20 patients with active rheumatoid arthritis ruled out the possibility that high PC: Ag is non-specific, acute-phase reaction to inflammation, tissue injury or neoplastic growth. Therefore, high PC:Ag might be specifically related to the thrombotic tendency of these patients, but the mechanism of such a relationship remains to be clarified.

Outcome of Treatment of Deep-Vein Thrombosis with Urokinase: Relationship to Dosage, Duration of Therapy, Age of the Thrombus and Laboratory Changes

Forty-one patients with phlebographically proven DVT of the popliteal, femoral or iliac veins were treated with different regimens of urokinase (UK) given by continuous intravenous infusion. The four groups were comparable with respect to localization, extension and estimated age of the thrombi. Another phlebographic picture was taken within 48 hr after the end of UK infusion. Substantial lysis had occurred in 2 of 10 patients treated with 1500 U/kg/h for 2 days, in 4 of 11 treated with 2500/U/kg/h for 3 days, in 2 of 10 treated with 2500 U/kg/h for 7 days and in 4 of 10 treated with 4000 U/kg/h for 4 days. Only thrombi younger than 8 days could be lysed, with 61% (8/13) rate of lysis for thrombi less than 5 days old. Bleeding complications were observed more frequently with the higher doses and longer durations of therapy. The four treatment regimens all induced dose-dependent changes in fibrinogen, fibrin(ogen) degradation products, plasminogen and antiplasmin. Neither pre- nor postinfusion values of these parameters could differentiate patients with lysis from those without lysis. It is concluded that UK can provoke a high rate of thrombolysis of DVT treated early after the appearance of symptoms but that there is no relationship between UK-induced modifications of fibrinolysis and the outcome of therapy.

Effect of a structured, active, home-based cancer-treatment program for the management of patients on oral chemotherapy

INTRODUCTION

The advent of oral chemotherapy agents has had a strong impact on several aspects of the management of cancer patients, including survival rates, health-care expenditure, and health-related quality of life. However, access to care and adherence to oral chemotherapy are central to optimal outcomes.

PATIENTS AND METHODS

In this multicenter observational study, we assessed the effect of the "Active Home Care" initiative - a structured, active, home-based cancer-treatment program - on quality of life, health-care utilization, and patient adherence and satisfaction using self-administered questionnaires. Sixty-two patients treated with oral chemotherapy (capecitabine, vinorelbine, imatinib, sunitinib, sorafenib, temozolomide, ibandronate) were enrolled in the program. Weekly home visits were scheduled, each one with a trained nurse who delivered the home-based chemotherapy and reviewed patients' compliance and treatment toxicity. An oncologist evaluated patients and modified the dosage of oral chemotherapy based on toxicity reported during the previous cycle at bi-weekly visits.

RESULTS

A total of 460 home visits were performed between April 2012 and February 2013. The Active Home Care initiative was associated with significant improvements in physical functioning and symptoms, and reductions in the access to cancer facilities. Satisfaction with oral chemotherapy and care received was high. All patients reported having taken their medications according to their prescription, and no patient reported difficulties in managing the oral chemotherapy regimen.

CONCLUSION

The Active Home Care program was associated with improvements in the quality of life of patients and caregivers, better adherence to treatment, and the effective management of therapy and cancer-related symptoms. Home-based cancer treatment may also optimize the utilization of health-care resources.

Aspirin (ASA) Inhibits both Prostacyclin and Thromboxane Formation in Man

The effects of two different doses (0,3-1,5 g) of ASA on platelet thromboxane (Tx) and endothelial prostacyclin (PCI2) formation have been investigated in 4 healthy adults. Both doses gave a complete suppression of TxB2 formation as measured by radioimmunoassay (RIA) of serum obtained 2 hours after ASA. PGI2 production was assessed with a bioassay based on the inhibition of ADP-induced platelet aggregation. The formation of PGI2-like inhibitory activity in vein specimens obtained at biopsy was abolished by either dose of ASA. In two subjects taking 0,3 and 1,5 g of ASA respectively, inhibition of PGI2 formation was confirmed by measuring 6-keto-PCF1α, the stable hydrolysis product of PGI2, by RIA. We have also studied a patient with an “aspirin-like” syndrome characterized by a mild congenital bleeding tendency, defective platelet release reaction, lack of aggregation by arachidonic acid and no TxB2 formation after thrombin. Venous biopsy specimens failed to produce PGI2 as measured by both bioassay and RIA. These studies show that the cyclo-oxygenase enzyme systems of human platelets and endothelial cells are both susceptible to Inhibition by ASA in vivo; and no difference was noted in the degree of inhibition induced with the two dosages. The congenital deficiency of both PCI2 and Tx formation in one patient was associated with a mild bleeding diathesis but no thrombosis tendency.