Patient-centered communication, patient satisfaction, and retention in care in assisted reproductive technology visits.

PURPOSE: To explore the association between patient-centered communication, patients' satisfaction, and retention in care in assisted reproductive technology (ART) visits. METHODS: ART visits at eight Italian clinics were videotaped and coded using the Roter Interaction Analysis System, which includes a Patient-Centered Index (PCI), a summary "patient-centered communication" ratio. After the visit, patients completed a satisfaction questionnaire (SATQ). After 3 months, patients were asked about their retention in care. Spearman correlations and Mann-Whitney tests were used to test associations between the study variables; the open-ended item of SATQ was analyzed through content analysis. RESULTS: Eighty-five visits were videotaped (involving 28 gynecologists and 160 patients). PCI score (µ = 0.51 ± 0.28) revealed a more disease-oriented communication during the visit. Patients reported high levels of satisfaction with the visit and identified in the information provision or in the doctor's humanity or kindness the main reasons of satisfaction. At the follow-up, the majority of the couples declared to have followed the clinicians' recommendations and to have remained related to the ART center. No associations were found among the study variables, except for a lower male satisfaction among couples who declared to have changed ART clinic. CONCLUSIONS: Contrary to what was expected, the style of physician-patient communication was not found to be associated with patient satisfaction and retention in care. However, patients were highly satisfied and engaged. The actual meaning of a communication that is "patient-centered" in the ART context might be wider, including the couples' need for information, as suggested by qualitative findings.

Doctor-couple communication during assisted reproductive technology visits.

STUDY QUESTION: What are the characteristics of doctor-couple communication content during actual ART visits? SUMMARY ANSWER: Physicians were mainly focused on providing biomedical information, while communication content from couples had a 2-fold focus on providing biomedical information and on positive talk. WHAT IS KNOWN ALREADY: Communication aspects in ART seem crucial for clinical decision-making, retention in care and critical conversations with couples due to low treatment success rates. However, no studies have been carried out on the actual interaction between the doctor and the couple in this context. STUDY DESIGN, SIZE, DURATION: This observational study involved 28 clinicians and 160 patients referred to eight Italian ART clinics during a one-year recruitment period. PARTICIPANTS/MATERIALS, SETTING, METHODS: ART visits at eight Italian clinics were videotaped. The visits were coded using the Roter Interaction Analysis System (RIAS), particularly focusing on RIAS composite categories, verbal dominance and patient-centeredness score. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 85 visits were eligible for analysis (62% acceptance rate), involving 28 clinicians and 160 patients (including 75 couples). The average visit duration was 37 ± 17.7 min. The mean verbal dominance was 1.9 ± 0.86 (range: 0.72-5.74). Physicians mainly focused on providing biomedical information. Communication content from couples had a 2-fold focus on providing biomedical information and on positive talk. The mean of patient centeredness index (PCI) was 0.51 (SD = 0.28; range 0.08-1.77); visits in which the doctor was a woman or the treatment indication was for heterologous fertilization showed higher PCI scores. Overall, females accounted for 67% of all patient talk. Taking this imbalance into account as expected frequencies for each composite category, males reported significantly more utterances in almost all of the socioemotional categories. LIMITATIONS, REASONS FOR CAUTION: These results are preliminary and observational and only regard Italy. Communication during visits may have been biased since the professionals who agreed to participate showed an interest in communication issues. Another limitation is a possible Hawthorne effect due to the fact that participants were aware of being videotaped. WIDER IMPLICATIONS OF THE FINDINGS: Our study showed that ART physicians mainly adopted an informative model of communication and a more disease-oriented approach. Findings revealed the complexity of communication content during ART consultations, given its triadic characteristic in which the third party is also a patient; clinicians should be aware of this complex aspect and of the specific male and female perspectives to be taken into account. The results could be useful for training ART professionals. STUDY FUNDING/COMPETING INTEREST(S): This study was possible thanks to an unconditional grant from Ferring Spa to the Department of Health Sciences, University of Milan. There are no competing interests to declare. TRIAL REGISTRATION NUMBER: N/A.

[Anti-sperm antibodies in dysspermia in spinal cord injury patients]. / Anticorpi antispermatozoo nelle dispermie di pazienti mielolesi.

A relatively uninvestigated area of reproductive physiology is the changes of sperm quality in the anejaculatory man. The retention of sperm cells may result in increased pressure in the genital tract, initiating an autoimmune response to sperm as seen in cases of congenital absence of the vas deferens and vasectomy. Reports on this matter are very contradictory. We evaluated antisperm antibodies in two groups of anejaculatory men with SCI. In the first group of 16 patients there was no clinical and laboratory urogenital infection. In the second group of 13 patients there was clinical and laboratory evidence for urogenital infection. Sperm antibodies were found in 12% of the patients of the first group and in 38% of the patients of the second group.

[Male sterility and artificial insemination using donor semen. Our experience]. / Sterilità maschile ed inseminazione artificiale con seme di donatore (A.I.D.). Nostra esperienza.

There has been a considerable increase in the demand for artificial insemination with donor semen (A.I.D.) in Italy during the past 5 years. This study describes the 4 year experience of an infertility practice which maintains a frozen bank as its primary source of A.I.D. The overall pregnancy rate was 52.27%. There is a significant difference in pregnancies in various age groups. Our pregnancy rate was 72.2% for those women under 31 and 31.5% for those over 31.

Reproductive aspects in spinal cord injured males.

Infertility in paraplegic males is determined by two major factors: (1) most patients with spinal cord lesions cannot ejaculate, and (2) if ejaculation is possible, then the features of the semen are constantly abnormal. Various methods have been proposed to stimulate the ejaculatory reflex in paraplegics. From 1983 we have used for this purpose a simple vibrator applied to the penis and with this method the ejaculatory response was obtained in 72 of 102 patients treated. Fifteen patients who desired a child, received instruction in self-using the vibrator at home weekly. Sperm characteristics were evaluated (mean of two samples) before and after 3 months of self-use of the vibrator. Statistical evaluation of the results was performed with Student t-test. At the end of the treatment an improvement of sperm concentration and progressive motility was evident, but the result of highest statistical significance was the decrease of abnormal sperm morphology. Three couples obtained a pregnancy with AIH.

A new criterion for the more exact evaluation of the swelling test.

The functional integrity of membranes of 12 semen samples from fertile men and 60 from male partners in couples with infertile marriage was assessed by hypoosmotic swelling test, eosin vitality test and swelling/eosin test. We found a mean swelling percentage of 75 +/- 2.7 for the group of subjects with proven fertility, while a mean of 72 +/- 9.24 was found for the group of infertile subjects. An amount of less than 60% was found in 7 of the latter group and only one less than 50%. By using the "swelling/eosin" test we obtained a mean of 66 +/- 5.5 for the first group of subjects. Instead we found a mean percentage of 55 +/- 14.3 for the second group; 9 of these subjects had values between 50 and 60 percent and 11 less than 50%. We didn't find statistically significant correlation between semen parameters and the swelling test and semen parameters and swelling/eosin test. The results we obtained lead us to suppose that the swelling/eosin test is more accurate than the swelling test alone.

Analysis of the action of corticosteroid treatment in immunologic infertility: a preliminary report and an alternative hypothesis.

The presence of sperm antibodies can be demonstrated in 8-10% of the male partners of infertile couples. The therapeutic schedule with which the highest pregnancy rate has been obtained in these cases is that proposed by Shulman, which uses methylprednisolone (MP). If treatment with corticosteroids (CS) is effective, the way in which it acts is not entirely clear. In this study we report the results of 16 treatment cycles with CS administered to eight male patients having sperm antibodies in their serum, in which several parameters of humoral immunity were evaluated. The results are conflicting: several parameters (such as IgG concentration) underwent only slight variations after 7 days of therapy, whereas in 12 cycles out of 16, the Tray agglutination test (TAT) indicated that a reduction or disappearance of the antibodies had been obtained. This confirms the usefulness of CS in immunological infertility, and allows us to hypothesize that the beneficial effect may be found in a reduction of inflammation rather than in a suppression of the immunological response, since CS are well known to have these two kinds of effect.

Seminal parameters and auto-immunity in paraplegic/quadraplegic men.

In the present paper seminal parameters in 142 males with spinal lesion have been testes. The occurrence of sperm antibodies in spinal cord injured males is frequent enough to be considered a causal factor in the reduction of fertility.

Immunoassayable somatomedin C in seminal plasma of azoospermic men.

Somatomedin C is a Sertoli cell peptide and since measurements of other Sertoli cell products in semen have provided a useful indices of testicular function, it was considered pertinent to measure the semen levels of Somatomedin C. Somatomedin C was measured by RIA in seminal plasma of vasectomized subjects (n = 18), subjects with agenesis of the seminal vesicles and vasa deferentia (n = 6) and subjects with azoospermia resulting from seminiferous tubule damage without obstruction (n = 23). Normal fertile subjects (24 men with a sperm concentration greater than 20 X 10(6)/ml) were used as controls. In all subjects, seminal levels of transferrin were also measured as an index of Sertoli cell function. The majority of seminal Somatomedin C appears to derive from the testis and/or epididymis. However, in several normal controls seminal levels of Somatomedin C (median = 3.52; range = 1.10-15.67 U/ejaculate) were found to be within the range for vasectomized subjects (median = 0.78; range = 0.46-4.20 U/ejaculate). In subjects with azoospermia the seminal levels of Somatomedin C (median = 2.06; range = 0.60-10.12 U/ejaculate) were significantly lower (P less than 0.02) than in fertile controls. However, values for these two groups overlapped. It is concluded that Somatomedin C in semen is not a reliable index of seminiferous tubule function and does not appear to be of diagnostic value in male infertility.

Approach to immunological male infertility: a comparison between MAR test and direct immunobead test.

A comparative study between MAR test and IBT in 142 seminal samples is presented by the authors and their concordance with TAT and SIT is also evaluated. In particular the interest of IBT for the evaluation of involved immunoglobulinic classes is stressed.

The imagined baby: the analysis of a desire.

Of the many people currently infertile, at least 40% have a problem related solely to the male. Feelings about infertility are based on something deeper and more engrained in a person's character called concepts. Concepts are formed by many forces such as religion, society, the value of others and so on. 61 males, partners of infertile couples, were invited to an interview using as a means of investigation a semistructured questionnaire. We focused our attention on the meaning these men gave to an eventual baby, and on the common opinion about a childless married man either from a social or an individual point of view. According to these criteria, we found that 42% of the people interviewed thought that "people" consider the lack of children as related to male impotence with remarkable differences between the opinion of those who lived in cities and those who did not. As for the solution prospected in the case of incurable sterility, 37% would chose to remain childless, a little lower percentage would choose a sperm bank and only 20% would choose adoption. The results of this research show that among many different aspects, the image of the baby for these applicant fathers is still linked to traditional values.

Hyperprolactinemia and 5-alpha-reductase activity.

A number of experimental data indicate that hyperprolactinemia inhibits the activity of 5-alpha-reductase; however, no information is available about the time required for this enzyme to re-activate after prolactinemia has returned to normal values. In the present study, five normal caucasian men, whose fertility had previously been proven, were given HCG (5000 IU/day by intramuscular route for three days) both in basal conditions and after sulpiride-induced hyperprolactinemia (dosage = 200 mg/day for ten days). In both conditions, the plasma levels of prolactin (PRL), testosterone (T), dihydro-testosterone (DHT), 17-beta-estradiol (E2), and dehydroepiandrosterone sulfate (DHAS) were monitored during the treatment with HCG and for an additional 24 hrs after HCG discontinuation. All hormones were assayed by RIA. Our results demonstrate that hyperprolactinemia causes a marked decrease (58%) of DHT, a less marked decrease (39%) of T, an increase (43%) of DHAS whereas only a small increase (2%) of E2 was observed. Steroids were shown to behave differently after the HCG tests performed in the two experimental conditions. In particular, the levels of DHT had a much more pronounced increased after HCG in the second test than in the first; in contrast, both DHAS and E2 had a less marked response after the second test. Our data, on the one hand, confirm that 5-alpha-reductase is inhibited by hyperprolactinemia; on the other hand, the hyperprolactinemia-induced block of this enzyme appears to be rapidly reversible because the enzyme is reactivated within 48-72 hrs after normalization of prolactin levels. (Normal values of prolactin were on the average achieved on the 4th day after sulpiride discontinuation).(ABSTRACT TRUNCATED AT 250 WORDS)

Cervical cap homologous artificial insemination (AIH): the University of Florence experience.

We report our experience with artificial insemination with husband's semen (AIH) using cervical cap. Forty-four couples were admitted to our AIH program over a two-year period. In 4 couples, AIH was performed due to impotence or hypospadia, while in the remaining 40 couples indications for AIH were abnormal semen, poor post-coital test, anti-sperm antibodies, poor cervical mucus. Overall, six pregnancies were obtained (pregnancy rate = 15%) in the latter group; in particular, AIH was able to elicit pregnancy in 5 out of the 25 cases of abnormal semen (20%). Our data emphasize the importance of female factors associated with infertility since significantly higher pregnancy rates (45.4% versus 0%) were observed in subjects in whom these factors were absent.

Effect of an alpha-blocking agent (phenoxybenzamine) in the management of premature ejaculation.

Phenoxybenzamine has been extremely effective in treating patients with vesical dysfunctions, its minimal side effects include anejaculation and delay and difficulty in ejaculation. Fifteen men were treated with phenoxybenzamine (PBZ) for premature ejaculation. Eight patients reported a subjective improvement of the time from penetration to ejaculation. PBZ is a well tolerated drug. The only side effect of the treatment was dry ejaculation. The Authors suggest its use in selected patients.

Chronic phospholipid liposomes administration and ovarian function.

In the past years, hypothalamic phospholipids (H-PL) have been used therapeutically for their behavioral effects. The major pharmacological effect of H-PLs is that they increase the turnover rate of biogenic amines in the brain. Previous studies have also shown that a single i.v. dose of H-PL may influence tha plasma levels of gonadotropins, prolactin (PRL) and growth hormone (GH). Since data have not yet been published concerning the effects, if any, of chronic i.m. administration of H-PL on the ovarian function, the present study was undertaken to gain insight into this issue. Four women were studied. Each subject was given H-PLs by i.m. injection from the 5th to the 20th day of the cycle at the dose of 100 mg/day. Blood samples were repeatedly taken over this period to measure the plasma concentrations of FSH, LH, E2, PRL, and progesterone. GH administration, no side-effects were noted in any of the subjects studied. All subjects presented normal plasma levels of FSH, LH, E2, PRL, and progesterone. GH demonstrated some upward fluctuations, which always regressed rapidly. Our findings demonstrate that chronic H-PL administration at therapeutic doses does not influence the ovarian cycle in women. In the light of our data, it appears that different hormonal effects are elicited by a single i.v. high-dose administration of H-PLs as compared with those produced by chronic i.m. treatment at therapeutic doses.

The MAR test as immunologic screening of male infertility.

The mixed antiglobulin reaction was developed for detection of platelet antibody and then modified to demonstrate antibodies on spermatozoa. We have used the test as a simple method of screening for antibodies in the male, performing the test during the analysis of semen samples. We evaluated 320 samples from partners of sterile couples attending our Sterility centers. The IgG MAR test was not applicable to 82 samples because the sperm concentration and sperm motility was not sufficient. In all uncertain, positive and firmly positive cases of MAR test and in 50 negative cases of IgG MAR test, as control group we performed MAR test for IgA. We correlate our results with the sperm test penetration, SCMC test and identification of antisperm antibodies test and Isojima test for sperm immobilizing antibodies. Our results reconfirm the utility of IgG MAR test as screening test for the presence of antibodies but its positiveness requires the performance of IgA MAR test and, if necessary, of other tests in order to diagnose sterility depending on immunologic factors.

Plasma concentrations of FSH and testosterone in male infertile patients.

We studied the statistical distribution of the plasma concentrations of FSH and testosterone in patients with oligoazoospermia as compared with normospermic subjects. The plasma concentration of FSH was determined in 429 patients with oligoazoospermia and 282 normospermic subjects ("controls"). In 118 out of these 429 patients and in 47 of the 282 controls, the plasma concentration of testosterone was also measured. The plasma concentrations of FSH differed significantly depending on the patients' values of spermatic concentration. The most significant difference was observed between azoospermic patients and controls, whereas the difference between patients with mild oligospermia and controls was not significant. Conversely, the plasma concentrations of testosterone did not correlate with the values of spermatic concentration and even the difference between azoospermic patients and controls did not reach the significance level. In addition, testosterone plasma concentrations did not differ between two sub-groups of patients who were defined depending on whether the plasma concentration of FSH was normal or high. Our findings confirm the inverse relation between plasma FSH levels and spermatic concentration which had already been observed in previous studies. However, a considerable overlap in the plasma concentrations of FSH has been found between sub-groups of patients with different spermatic concentrations. This overlap limits the clinical usefulness of the measurement of FSH concentration inasmuch as normal FSH plasma levels may often be associated with any value of spermatic concentration. Also, our data confirm that the measurement of testosterone plasma levels provides little clinical usefulness in male infertile patients.

Tamoxifen and oligospermia.

Thirty normogonadotropic oligospermic males were administered Tamoxifen (20 mg/day) for 4 months. A complete evaluation of seminal parameters before and after treatment was performed. An increase of both mean sperm concentration and total sperm count was noted after treatment with Tamoxifen (p less than 0.05), whereas no variation was observed for semen volume, sperm morphologic characteristics, or sperm motility. Hormonal patterns of 5 of these subjects before, during, and after 3 months of treatment with Tamoxifen showed a progressive increase of gonadotropin (especially LH) and 17 beta E2 values; testosterone variations were minimal, and PRL showed a slight decrease.

Dynamic echohysteroscopy: new perspectives for diagnostic sonography in female infertility.

Dynamic echohysteroscopy is a new diagnostic method which can be applied to the clinical problems of infertility, providing informations on the morphology of the internal genitals. The Authors underline the clinical validity of this diagnostic technique, even though more experience is required in order to define a better standardization of the method.