Perceived challenges of working in a fertility clinic: a qualitative analysis of work stressors and difficulties working with patients.

STUDY QUESTION: What are some of the challenges of working in a fertility clinic? SUMMARY ANSWER: The most frequently mentioned challenges were workload (e.g. high time pressure) and patient-related sources (e.g. unrealistic expectations). WHAT IS KNOWN ALREADY: One study showed a too high workload, worry about handling human material and low success rates were main stressors in fertility clinics. STUDY DESIGN, SIZE, DURATION: An online open-ended survey inviting participants to respond to seven questions was distributed to 5902 members of the European Society for Human Reproduction and Embryology (ESHRE, October 2010). Questions asked participants to describe the top three factors that made (i) their work stressful (hereafter 'Work stressors') and (ii) working with patients difficult (hereafter 'Perceived sources of difficulties'), and (iii) to choose from these factors which top three issues they would be willing to attend a workshop to resolve (hereafter 'Workshops'). A qualitative content analysis using inductive coding for each question was used to extract meaningful themes from the text replies, at three levels of increasing abstraction (lower and higher categories, general themes). PARTICIPANTS/MATERIALS, SETTING, METHODS: The final sample comprised 526 respondents (8.9% participation rate). Respondents were predominantly clinicians (41.3%, n = 216) or embryologists (35.5%, n = 186) from European countries (73.0%, n = 386). MAIN RESULTS AND THE ROLE OF CHANCE: The number of text replies generated for each question was 1421, 1208 and 907 for the 'Work Stressors', 'Perceived sources of difficulties' and 'Workshop' questions, respectively. The most often reported higher-order categories of Work Stressors were 'Time and Workload' (61.6%, e.g. time pressure), 'Organisation, Team and management issues' (60.4%, e.g. team conflicts) and 'Job content and work environment' (50.3%, e.g. burdensome administration). For 'Perceived sources of difficulties' these were 'Patient-related sources' (66.7%, e.g. unrealistic expectations), 'Communication and Counselling with patients' (33.7%, e.g. strained information giving) and 'Misinformation and lack of knowledge' (27.8%, e.g. Dr Google). Finally, the topics participants would be willing to address in Workshops were 'Communicating and Counselling with Patients' (24.9%), 'Dealing with Patient-related sources' (19.6%) and 'Clinical topics' (19.6%). Three general themes emerged. First, a theme of 'time and time trade-offs' expressed the oft-mentioned need to trade-off time spent on one activity (e.g. managing patient demands) against another activity (e.g. clinical workload, administration) with stress level dependent on the efficacy of trading-off. Second, the theme of 'multifactorial causes' of challenging patient interactions that embodied the many sources of difficulties working with patients. What staff would be willing to address in workshops was indicated by the final general theme of 'a little of everything', which linked to the need for multiple workshops addressing the multifactorial nature of challenges in fertility clinics. LIMITATIONS, REASONS FOR CAUTION: Only about 10% of members receiving the survey participated. The work was limited to the stressful and difficult aspects of working in fertility clinics, which may give a more negative impression than if questions about the rewards and benefits had also been included. WIDER IMPLICATIONS OF THE FINDINGS: The nature of stressors and difficulties of working in a fertility clinic are consistent with models of occupational stress and patient complexity. Specialized psychologists, management consultants and other occupational experts could assist fertility teams in overcoming many of the challenges. More research is required on the effect of encountered work stressors and perceived sources of difficulties in working with patients on staff and patient outcomes. STUDY FUNDING/COMPETING INTERESTS: None declared.

Fertility knowledge and beliefs about fertility treatment: findings from the International Fertility Decision-making Study.

STUDY QUESTION: How good is fertility knowledge and what are treatment beliefs in an international sample of men and women currently trying to conceive? SUMMARY ANSWER: The study population had a modest level of fertility knowledge and held positive and negative views of treatment. WHAT IS KNOWN ALREADY: Few studies have examined general fertility treatment attitudes but studies of specific interventions show that attitudes are related to characteristics of the patient, doctor and context. Further, research shows that fertility knowledge is poor. However, the majority of these studies have examined the prevalence of infertility, the optimal fertile period and/or age-related infertility in women, in university students and/or people from high-resource countries making it difficult to generalize findings. STUDY DESIGN, SIZE, DURATION: A cross-sectional sample completed the International Fertility Decision-making Study (IFDMS) over a 9-month period, online or via social research panels and in fertility clinics. PARTICIPANTS/MATERIALS, SETTING, METHODS: Participants were 10 045 people (8355 women, 1690 men) who were on average 31.8 years old, had been trying to conceive for 2.8 years with 53.9% university educated. From a total of 79 countries, sample size was >100 in 18 countries. All 79 countries were assigned to either a very high Human Development Index (VH HDI) or a not very high HDI (NVH HDI). The IFDMS was a 45-min, 64-item English survey translated into 12 languages. The inclusion criteria were the age between 18 and 50 years and currently trying to conceive for at least 6 months. Fertility knowledge was assessed using a 13-item correct/incorrect scale concerned with risk factors, misconceptions and basic fertility facts (range: 0-100% correct). Treatment beliefs were assessed with positive and negative statements about fertility treatment rated on a five-point agree/disagree response scale. MAIN RESULTS AND THE ROLE OF CHANCE: Average correct score for Fertility Knowledge was 56.9%, with greater knowledge significantly related to female gender, university education, paid employment, VH HDI and prior medical consultation for infertility (all P < 0.001). The mean agreement scores for treatment beliefs showed that agreement for positive items (safety, efficacy) was correlated with agreement for negative items (short/long-term physical/emotional effects) (P > 0.001). People who had given birth/fathered a child, been trying to conceive for less than 12 months, who had never consulted for a fertility problem and who lived in a country with an NVH HDI agreed less with negative beliefs. HDI, duration of trying to conceive and help-seeking were also correlates of higher positive beliefs, alongside younger age, living in an urban area and having stepchildren. Greater fertility knowledge was associated with stronger agreement on negative treatment beliefs items (P < 0.001) but was unrelated to positive treatment beliefs items. LIMITATIONS, REASONS FOR CAUTION: There was volunteer bias insofar as more women, people of higher education and people with fertility problems (i.e. met criteria for infertility, had consulted a medical doctor, had conceived with fertility treatment) participated and this was true in VH and NVH HDI countries. The bias may mean that people in this sample had better fertility knowledge and less favourable treatment beliefs than is the case in the general population. WIDER IMPLICATIONS OF THE FINDINGS: Educational interventions should be directed at improving knowledge of fertility health. Future prospective research should be aimed at investigating how fertility knowledge and treatment beliefs affect childbearing and help-seeking decision-making.

Knowledge about infertility risk factors, fertility myths and illusory benefits of healthy habits in young people.

BACKGROUND: Previous research has highlighted a lack of fertility awareness in the general population especially in relation to the optimal fertile period during the menstrual cycle, incidence of infertility and duration of the reproductive life span. The current study assessed fertility knowledge more broadly in young people and investigated three areas of knowledge, namely risk factors associated with female infertility (e.g. smoking), beliefs in false fertility myths (e.g. benefits of rural living) and beliefs in the illusory benefits of healthy habits (e.g. exercising regularly) on female fertility. METHOD: The sample (n = 149) consisted of 110 female and 39 male postgraduate and undergraduate university students (average age 24.01, SD = 7.81). Knowledge scores were based on a simple task requiring the participants to estimate the effect a factor would have on a group of 100 women trying to get pregnant. Items (n = 21) were grouped according to three categories: risk factors (e.g. smoking; 7 items), myths (e.g. living in countryside; 7 items) and healthy habits (e.g. being normal weight; 7 items). RESULTS: An analysis of variance showed a significant main effect of factor (P < 0.001) and post hoc tests revealed that young people were significantly better at correctly identifying the effects of risks compared with null effects of healthy habits (P < 0.001) or fertility myths (P < 0.001). CONCLUSION: Young people are aware that the negative lifestyle factors reduce fertility but falsely believe in fertility myths and the benefits of healthy habits. We suggest that the public education campaigns should be directed to erroneous beliefs about pseudo protective factors.

Causal explanations for lack of pregnancy applying the common sense model of illness representation to the fertility context.

OBJECTIVES: The current study explored causal explanations for lack of pregnancy and association with help-seeking behaviour. Differences based on gender and country Human Development Index were examined. DESIGN: A mixed method design was used. MAIN OUTCOME MEASURES: Data were drawn from the International Fertility Decision-Making Study, a cross-sectional study of 10,045 individuals (1690 men; 8355 women) from 79 countries. Respondents rated to what extent they believed their lack of pregnancy was due to something they or their partner had done/not done or other factors and described their reasons for making this rating. RESULTS: Respondents were aged 18-50 (M = 31.83) years, partnered and had been trying to achieve a pregnancy/father a child for over six months (M = 2.8 years). Men and women primarily believed their lack of pregnancy was due to medical problems or chance/bad luck. Thematic analysis of textual responses from 29.7% of the sample found that respondents focused on their personal experience or a salient life event when describing the cause of their lack of pregnancy. Women expressed more regret and helplessness about causes than men. Significant country differences were observed. CONCLUSIONS: Individuals may develop inaccurate causal explanations based on their personal experiences. Access to accurate information is necessary to facilitate timely help-seeking.

Correlates of fertility issues in an internet survey of cancer survivors.

PURPOSE: The objectives of this study were (1) to determine what young cancer survivors know about the effect of their cancer on fertility, how fertility difficulties affected their lives and whether they would opt for fertility preservation (FP) and (2) to assess the sources of information and the helpfulness of them. METHODS: Women of at least 18 years with cancer affecting reproductive function were recruited from eight cancer websites for this online survey. The Cancer and Fertility Survey (CFS) contained items from validated inventories and items to assess fertility issues in cancer patients. Quantitative analyses (t-tests, chi(2), analysis of variance) and thematic analysis of free text data were performed. RESULTS: Of the 80 participating women, 68.1% rated the risk of infertility as high. The mean number of professionals consulted was 3.56 (SD = 2.7), but 20% of women had not discussed fertility with any professional. The weighted mean helpfulness index was the highest for spouses and oncologists. Strength of positive attitudes towards FP was significantly greater than that of negative attitudes. CONCLUSION: The need to discuss fertility is high among women searching for information on cancer websites. Options to preserve fertility were positively viewed but the actual use may be limited by concerns about safety.

Decision-making about seeking medical advice in an internet sample of women trying to get pregnant.

INTRODUCTION: In light of the near universal desire to become a parent one would expect most people to seek medical advice if they were experiencing difficulties conceiving. Yet less than 55% do so and we sought to understand more about this paradox by comparing the psychosocial profile and decision-making of women not yet engaged in the medical process to that of those who had consulted. METHODS: A Fertility Decision-Making Questionnaire was designed and posted on a website dedicated to women trying to conceive. RESULTS: A total of 426 women completed the questionnaire, 56% had not yet consulted a doctor about conceiving (non-consulter, NC). Women who had sought treatment had more positive treatment beliefs, and a greater willingness to know if a problem existed, than those who had not yet consulted. Almost 20% of NC women already met the medical definition of infertility and this subgroup had a greater fear of discovering a problem and of being labelled infertile than other women in the study. CONCLUSIONS: Seeking medical advice for fertility problems is mainly associated with what women know or want to know about their fertility and their emotional reactions to that knowledge. Negative reactions can substantially delay seeking help in 20% of women.

International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care.

INTRODUCTION The purpose of the present study was to review existing population surveys on the prevalence of infertility and proportion of couples seeking medical help for fertility problems. METHODS Population surveys, reporting the prevalence of infertility and proportion of couples seeking help in more and less developed countries, were reviewed. RESULTS Estimates on the prevalence of infertility came from 25 population surveys sampling 172 413 women. The 12-month prevalence rate ranged from 3.5% to 16.7% in more developed nations and from 6.9% to 9.3% in less-developed nations, with an estimated overall median prevalence of 9%. In 17 studies sampling 6410 women, the proportion of couples seeking medial care was, on average, 56.1% (range 42-76.3%) in more developed countries and 51.2% (range 27-74.1%) in less developed countries. The proportion of people actually receiving care was substantially less, 22.4%. Based on these estimates and on the current world population, 72.4 million women are currently infertile; of these, 40.5 million are currently seeking infertility medical care. CONCLUSIONS The current evidence indicates a 9% prevalence of infertility (of 12 months) with 56% of couples seeking medical care. These estimates are lower than those typically cited and are remarkably similar between more and less developed countries.