How to talk to young adults about fertility.

RESEARCH QUESTION: How knowledgeable are Danish young adults about fertility and what are their attitudes towards learning about their reproductive biology? DESIGN: The study was conducted at different educational institutions with 11 focus-group discussions that included a total of 47 participants (aged 18-29 years). Qualitative content analysis was used. The participants' fertility knowledge score was measured using the Cardiff Fertility Knowledge Scale. RESULTS: The participants had an overall fertility knowledge score of 54%. Focus-group data showed that they thought it was important to learn about fertility and how to protect their fertility potential regardless of whether or not they wanted children. Providing knowledge is like planting a seed in the young adults. They wanted to hear about fertility in multifaceted ways and formats, and believed the information should be delivered by professionals, but developed in partnership with young people. The double-edged sword of knowledge and the consequence of knowledge made them hesitant or less open to learning. CONCLUSIONS: Recommendations from this study are to tailor fertility information to young people, with due cognisance of their developmental stage, and ideally from an earlier age.

Single mothers by choice - experiences of single women seeking treatment at a public fertility clinic in Denmark: A pilot study.

PROBLEM: There has been an increase in the number of single women deciding to have children through the use of medically assisted reproduction (MAR). These women are referred to as 'single mothers by choice' (SMC). BACKGROUND: Previous studies have shown how SMC can feel stigmatised. AIM: Explore if single women seeking fertility treatment in Denmark feel stigmatised. METHODS: Six single women undergoing MAR at a public fertility clinic in Denmark were interviewed. The interviews were audiotaped, anonymised, and transcribed in full, after provided written consent by the participants to take part in the study. Data were analysed using qualitative content analysis. FINDINGS: The women would have preferred to have a child in a relationship with a partner. Despite their dream of the nuclear family meaning a family group consisting of two parents and their children (one or more), the women choose to become SMC because motherhood was of such importance, and they feared they would otherwise become too old to have children. The participants did not experience stigma or negative responses to their decision, but they all had an awareness of the prejudices other people might have towards SMC. CONCLUSION: This study contributes to the understanding of the experiences of single women seeking fertility treatment in a welfare state where there are no differences in the possibilities for different social classes to seek MAR.

Fertility education: recommendations for developing and implementing tools to improve fertility literacy†.

Many recent societal trends have led to the need for fertility education, including the age at which individuals become parents, the development of new reproductive technologies, and family diversity. Fertility awareness has emerged as a concept very recently and is increasingly gaining recognition. However, fertility education is often neglected as there is no consensus on the appropriate content, target populations, or on who should provide it. This article attempts to provide an overview of the use of interventions to improve fertility education. We emphasize the importance of delivering evidence-based information on fertility and reproductive health through various methods while providing guidelines for their standardization and systematization. Recommendations are provided to aid the development and implementation of fertility education tools, including: the establishment of a comprehensive understanding of the target populations; the incorporation of theories of behavioural change; the inclusion of the users' perspectives and the use of participatory research; and the use of specific guidelines for increasing engagement. By following these recommendations, it is expected that fertility education resources can contribute to improving fertility literacy, empowering individuals and couples to make informed reproductive decisions, and ultimately reducing the incidence of infertility and need for fertility treatment.

Psychosocial wellbeing shortly after allocation to a freeze-all strategy compared with a fresh transfer strategy in women and men: a sub-study of a randomized controlled trial.

STUDY QUESTION: Is the psychosocial wellbeing affected in women and men shortly after allocation to a freeze-all strategy with postponement of embryo transfer compared to a fresh transfer strategy? SUMMARY ANSWER: In general, psychosocial wellbeing (i.e. emotional reactions to the treatment, quality-of-life, infertility-related stress, and marital benefit) was similar in women and men allocated to a freeze-all versus those allocated to a fresh-transfer strategy 6 days after disclosure of treatment strategy (i.e. 4 days after oocyte retrieval), although women in the freeze-all group reported a slightly higher degree of depressive symptoms and mood swings compared to women in the fresh transfer group. WHAT IS KNOWN ALREADY: The use of a freeze-all strategy, i.e. freezing of the entire embryo cohort followed by elective frozen embryo transfer in subsequent cycles has increased steadily over the past decade in assisted reproductive technology (ART). This strategy essentially eliminates the risk of ovarian hyperstimulation syndrome and has proven beneficial regarding some reproductive outcomes in subgroups of women. However, patients experience a longer time interval between oocyte retrieval and embryo transfer, hence a longer time to pregnancy, possibly adding additional stress to the ART treatment. So far, little focus has been on the possible psychosocial strains caused by postponement of embryo transfer. STUDY DESIGN, SIZE, DURATION: This is a self-reported questionnaire based sub-study of a multicentre randomized controlled trial (RCT) including 460 women and 396 male partners initiating their first, second, or third treatment cycle of invitro fertilisation or intracytoplasmic sperm injection (ICSI) from May 2016 to September 2018. This sub-study was included in the primary project protocol and project plan for the RCT, as psychosocial wellbeing was considered a secondary outcome. PARTICIPANTS/MATERIALS, SETTING, METHODS: Women from eight public fertility clinics in Denmark and Sweden and one private clinic in Spain were randomized in a 1:1 ratio on the day of inclusion (menstrual cycle day 2 or 3) to either a freeze-all strategy with postponement of embryo transfer to a subsequent modified natural menstrual cycle or a fresh transfer strategy with embryo transfer in the hormone stimulated cycle. Treatment allocation was blinded until the day of the ovulation trigger. Women and their male partners were asked to complete a validated self-reported questionnaire 6 days after unblinding of treatment group allocation, corresponding to 4 days after oocyte retrieval, investigating their psychosocial wellbeing related to the treatment defined as emotional reactions to the treatment, quality-of-life, infertility-related stress, and marital benefit. The questionnaire included items from the Copenhagen Multi-Centre Psychosocial Infertility (COMPI) Fertility Problem Stress Scales and the COMPI Marital Benefit Measure. MAIN RESULTS AND THE ROLE OF CHANCE: Baseline characteristics were comparable between the two groups for both women and men. In total, response rates were 90.7% for women and 90.2% for men. In the freeze-all group, 207 women and 179 men completed the questionnaire compared with 204 women and 178 men in the fresh transfer group. Men in the two treatment groups did not differ in any of the explored aspects of psychosocial wellbeing (i.e. emotional reactions to the treatment, quality-of-life, infertility-related stress, and marital benefit) 6 days after disclosure of treatment strategy. Women in the freeze-all group reported a slightly higher degree of depressive symptoms (P = 0.045) and mood swings (P = 0.001) (i.e. variables included in 'emotional reactions to treatment') compared to women in the fresh transfer group. When adjusted for multiple testing, depressive symptoms were no longer significantly different between the two groups. No additional differences in psychosocial wellbeing were found. Self-reported quality-of-life during treatment was also rated as similar between the two groups in both women and men, but was slightly lower than they would rate their quality-of-life when not in fertility treatment. LIMITATIONS, REASONS FOR CAUTION: Although response rates were high, selection bias cannot be excluded. As this study was an RCT, we assume that psychosocial characteristics of the participants were equally distributed in the two groups, thus it is unlikely that the identified psychosocial differences between the freeze-all and fresh transfer group were present already at baseline. Furthermore, the questionnaire was completed as a one-time assessment 4 days after oocyte retrieval, thus not reflecting the whole treatment process, whereas an assessment after the full completed treatment cycle is needed to draw firm conclusions about the psychosocial consequences of the whole waiting period. However, a question posted that late would be highly biased on whether or not a pregnancy had been achieved. WIDER IMPLICATIONS OF THE FINDINGS: The results indicate that individuals in the freeze-all group exhibited slightly higher levels of depressive symptoms and mood swings compared to those in the fresh transfer group. Nevertheless, it is important to note that any worries related to potential emotional strains stemming from delaying embryo transfer should not overshadow the adoption of a freeze-all approach in cases where it is clinically recommended. As long as patients are provided with comprehensive information about the treatment strategy before initiating the process, it is worth emphasising that other aspects of psychosocial wellbeing were comparable between the two groups. STUDY FUNDING/COMPETING INTEREST(S): The study is part of the Reprounion collaborative study, co-financed by the European Union, Interreg V Öresund-Kattegat-Skagerrak. L.P. reports financial support from Merck A/S. H.S.N. reports grants from Freya Biosciences ApS, Ferring Pharmaceuticals, BioInnovation Institute, Ministry of Education, Novo Nordic Foundation, Augustinus Fonden, Oda og Hans Svenningsens Fond, Demant Fonden, Ole Kirks Fond and Independent Research Fund Denmark and personal fees from Ferring Pharmaceuticals, Merck A/S, Astra Zeneca, Cook Medical, IBSA Nordic and Gedeon Richter. H.S.N is founder and chairman of the Maternity Foundation and co-developed the Safe Delivery App (non-profit). N.C.F. reports grants from Gedeon Richter, Merck A/S, Cryos International and financial support from Ferring Pharmaceuticals, Merck A/S and Gedeon Richter. N.C.F. is chairman in the steering committee for the guideline groups for The Danish Fertility Society (non-profit). P.H. reports honoraria from Merch A/S, IBSA Nordic and Gedeon Richter. A.L.M.E. reports grants and financial support from Merck A/S and Gedeon Richter. A.P. reports grants from Gedeon Richter, Ferring Pharmaceuticals, Merck A/S and personal fees from Preglem S.A., Novo Nordic Foundation, Ferring Pharmaceuticals, Gedeon Richter, Cryos International, Merch A/S, Theramex and Organon and the lend of embryoscope to the institution from Gedeon Richter. All other authors declare no conflict of interest. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov NCT02746562.

Young men's perceptions and attitudes towards two fertility awareness interventions and preferences for future initiatives.

This study explored young Danish men's perceptions and attitudes towards two fertility awareness (FA) interventions (a podcast episode and an informational poster) and their preferences for how fertility awareness and prevention efforts should be targeted and communicated to young men in the future. Focus groups were held with 13 young men who were between the ages of 25-35 and in a committed relationship over Zoom in January 2021. Data were analysed using qualitative content analysis. Young men preferred FA interventions to be factual as in the informational poster and to include personal stories that could serve as conversation starters as in the podcast. According to the young men, FA interventions should communicate using positive language and humour and not be negative or shaming. They preferred intervention formats like TV-programmes, podcasts, and social media. The participants also suggested fertility information should be included in sexual education in high school and vocational education. This research suggests that future FA campaigns should be developed in cooperation with the target group together with clinicians, and concurrent studies using different intervention formats should be performed. In all probability, a mix of different interventions is necessary to attain the desired effect to ensure long-lasting fertility awareness.

The importance of the 'family clock': women's lived experience of fertility decision-making 6 years after attending the Fertility Assessment and Counselling Clinic.

This study explored women's lived experience of making fertility decisions six years after attending the Fertility Assessment and Counselling (FAC) clinic in Copenhagen, Denmark, which is a personalised fertility awareness intervention. We conducted a qualitative interview study with 24 women who attended the FAC clinic 6 years earlier. Interviews were semi-structured and broadly examined the women's perceptions and experience of the intervention during follow-up. Data was analysed using a phenomenological framework and themes were identified related to women's experience of making fertility decisions after attending the FAC clinic. The overarching theme regarding the women's lived experience of making fertility decisions after attending the FAC clinic was: Fertility decisions were guided by the 'family clock'. There were four themes: (i) Deciding to 'get started' by attending the FAC clinic; (ii) Sense of making informed and empowered decisions; (iii) Influence of partner status on fertility decisions; and (iv) Decisions dictated by circumstance over preference and knowledge. At follow-up, the majority (21 women, 88%) had become parents. More than half of the women said that they had not achieved their desired family size. Consideration of women's 'family clock' is necessary in personalised fertility awareness interventions to enable women to achieve their family goals.

Examining gender effects in postdivorce adjustment trajectories over the first year after divorce in Denmark.

Research into gender and postdivorce mental and physical health has been highly inconsistent. The Gender Similarities Hypothesis suggests there are more similarities than differences and the Divorce Stress Adjustment Perspective suggests that structural inequalities may contribute to adverse postdivorce outcomes. We conducted secondary analyses from an RCT study to investigate if there were gender-specific trajectories and whether gender was associated with outcomes (self-perceived stress, symptoms of anxiety, depression, and somatization, general hostility, and overall mental and physical health) after controlling for effects of the intervention, income, and number of children using linear mixed-effect regression modeling, and whether number of children and income influenced these outcomes. Participants were 1,239 women and 617 men from the Cooperation after Divorce (CAD) study, conducted in Denmark, a country with less income disparity, high gender equality, shared childrearing by men and women, and societal acceptance of divorce. The analyses assessing the relationship between gender and 12-month postdivorce adjustment in terms of physical and mental health outcomes revealed that for self-perceived stress, symptoms of anxiety, depression, and somatization, hostility, and overall mental and physical health in this sample postdivorce adjustment trajectories were not gender-specific, and gender was only significantly associated with stress and somatization as a time-invariant additive effect. These findings suggest gender similarities in postdivorce adjustment and contribute to the Gender Similarities Hypothesis and the Divorce-Stress-Adjustment-Perspective by assessing individuals' postdivorce adjustment in a low-stigma and relatively egalitarian setting, providing a clearer assessment of the role of gender without potentially confounding issues of structural inequalities. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A qualitative study on couples' attitudes and concerns regarding a freeze all strategy in ART treatment.

The freeze all strategy has become a promising alternative to fresh embryo transfer in fertility treatment almost eliminating late ovarian hyperstimulation syndrome (OHSS) in the segmented cycle. There is a lack of in-depth knowledge regarding patients' attitudes towards the freeze all strategy. The aim of this study was to explore the attitudes towards a freeze all strategy compared with fresh embryo transfer in assisted reproductive technology (ART) treatment among couples in a public health care setting. We conducted semi-structured qualitative interviews with ten couples already participants in a randomised controlled trial (RCT) and undergoing ART treatment. The couple's responses showed five themes: (i) Starting treatment provides needed relief; (ii) Treatment must be provided with humanity; (iii) Provision of information instigates positive attitudes towards treatment; (iv) Fresh treatment - 'The normal way'; and (v) Freeze all treatment - 'The new black'. When thorough information about treatment procedures and safety aspects regarding both the freeze all and fresh embryo transfer strategy is given prior to initiation of treatment, couples feel secure and content, regardless of which treatment strategy is finally applied. This qualitative study found that starting treatment could prompt longed-for relief, as professionals would now 'take over' and assist in meeting the couple's family building goals.

Quality of life of Sudanese patients attending a fertility clinic: a mixed methods study.

BACKGROUND: Infertility affects over 50 million people globally, the burden is disproportionately borne by women, especially in low and middle-income countries (LMIC). The impact of infertility on quality of life (QoL) has not been well documented or assessed qualitatively in LMIC like Sudan, where infertility is a pervasive problem. Therefore, the purpose of this mixed-methods study was to assess the fertility-related QoL of infertile individuals in Sudan using the fertility quality of life (FertiQoL) tool. METHODS: We used explanatory sequential design (surveys and interviews) in a fertility clinic in Sudan (January 2017-May 2018). We collected socio-demographic information, medical/reproductive history and used Arabic FertiQoL. We generated descriptive statistics of FertiQoL (core, domain) scores and independent variables; multiple linear regression models to assess the relationship between FertiQoL and dependent variables; and t-tests to compare mean core/domain scores. We conducted thematic analysis on qualitative data about the subjective experience of being infertile. RESULTS: The study included 102 participants (72 women), 70 educated beyond secondary school, mean age 33.89 years (SD = 7.82) and mean duration of infertility was 4.03 years (SD 3.29). Mean FertiQoL core score 76.02 (SD = 16.26), domain scores: emotional 71.61 (SD = 22.04), relational 78.06 (SD = 16.62), mind/body 74.06 (SD 22.53) and social 78.88 (SD = 18.24). Men had better fertility-related QoL. FOUR THEMES EMERGED: A sense of something missing because of childlessness; social pressure from peoples' questions; impact on the spousal relationship (which differed amongst participants) and coping (faith-based and non-faith-based) which was necessary when the lived experience led to internal distress. CONCLUSIONS: Infertility negatively impacted the QoL of participants in this study, and women were worse off. Cognitive appraisal, social support and pressure may be key factors influencing the QoL of infertile individuals, therefore they should be encouraged to seek social and professional support. FertiQoL is a useful tool to assess fertility QoL in LMIC like Sudan.

Meditation and mindfulness reduce perceived stress in women with recurrent pregnancy loss: a randomized controlled trial.

RESEARCH QUESTION: Can participating in a tailored 7-week meditation and mindfulness programme with additional standard supportive care versus standard supportive care only reduce perceived stress for women with recurrent pregnancy loss (RPL)? DESIGN: A two-armed randomized controlled trial (RCT) with 12-month follow-up. In total 76 patients were enrolled and randomly assigned to either standard supportive care or to a 7-week meditation and mindfulness programme led by an instructor in addition to standard supportive care. RESULTS: At intervention completion (after 7 weeks), perceived stress decreased significantly both in the intervention group (P = 0.001) and in the control group (P = 0.006). The decrease in perceived stress in the intervention group was significantly larger (P = 0.027) compared with the control group. At the 12-month follow-up perceived stress was still significantly decreased in both groups compared with baseline (P < 0.0001 in the intervention group and P = 0.002 in the control group). CONCLUSION: This first RCT of a tailored meditation and mindfulness intervention for women with RPL documents that a 7-week daily at-home meditation and mindfulness programme combined with group sessions reduced perceived stress significantly more than a standard supportive care programme. Future studies should address the most effective format and the 'dose' needed for an impact on perceived stress levels.

Fertility quality of life tool: update on research and practice considerations.

The 36-item Fertility Quality of Life (FertiQoL) tool is increasingly used in research and practice. It measures quality of life in four personal domains (emotional, social, relational, mind/body) and two treatment domains (tolerability, environment). A literature review of published empirical research using FertiQoL was undertaken to provide an overview of this research base. Five databases were searched using 'FertiQoL' and its variant. In total, 41 published articles from 35 independent samples in 23 countries involving 16,315 participants, mainly in clinical settings, were reviewed. FertiQoL was used for three main purposes: (i) to assess quality of life and FertiQoL measurement properties (especially Core FertiQoL) using cross-sectional designs; (ii) to identify correlates, predictors, and consequences of fertility quality of life (some of which included international comparisons); (iii) to assess the effect of psychological interventions on fertility quality of life. The range of median FertiQoL Core, Treatment and subscale (scaled) scores in 31 samples was between 60 and 75. Poorer fertility quality of life was consistently associated with being a woman, longer duration of infertility, poorer psychological functioning and lower patient-centred care. Some FertiQoL subscale scores improved after psychological interventions. Future research should address measurement issues and examine reported associations with fertility quality of life.

A Qualitative Exploration of Women's Experiences of Living With Chronic Vulvar Dermatoses.

BACKGROUND: Many vulvar dermatoses (VDs) are chronic and cannot be "cured," thus affected women must learn to live with the impact of the disease, and its treatment, on their quality of life. AIM: To qualitatively investigate the impact of VDs on women's quality of life through firsthand accounts. METHODS: 12 women, 7 with lichen sclerosus and 5 with erosive vulvovaginal lichen planus recruited from a vulvar disease clinic participated in in-depth, exploratory interviews. Scripts were analyzed by applying a thematic network. The following steps were used: (1) coding the text, (2) development of descriptive themes, and (3) generation of thematic networks. OUTCOMES: The main outcome explored was the narrative experiences of women living with VDs. RESULTS: A global theme of suffering emerged. Themes associated with this suffering were organized under the themes of isolation, interference, and grieving. Women felt isolated because they felt unable to talk about their suffering; experienced a lack of external validation and support; and felt different as individuals, women, and sexual beings. Most women expressed negative views of their genitalia. Women spoke of the VDs, and its management, as interfering with thoughts, activities, and sex life. Symptoms were described as all-encompassing. Women spoke about limiting and/or avoiding daily activities and, in particular, sexual activities. Women described diminished sexual pleasure and experienced loss in their intimate relationships. Women described an ongoing grieving process; anger and sadness over the loss of their former healthy self; the burden of ongoing treatment; and attempts to cope and accept their current condition. CLINICAL IMPLICATIONS: The findings suggest that assessment of women with VDs should include a detailed history of the impact of the VDs on women's psychological and sexual health. STRENGTHS AND LIMITATIONS: A strength of this study is that we openly explored the lived experiences of women who had been clinically diagnosed with vulvar lichen sclerosus and erosive vulvovaginal lichen planus. A limitation is that the findings may not represent the experience of women living with VDs who do not wish to discuss their VDs or who are undiagnosed, untreated, and/or treated by other health-care providers. CONCLUSIONS: Women described profound impact of VDs on psychological and sexual health. Sadownik LA, Koert E, Maher C, et al. A Qualitative Exploration of Women's Experiences of Living With Chronic Vulvar Dermatoses. J Sex Med 2020;17:1740-1750.

Status one year after fertility assessment and counselling in women of reproductive age-a qualitative study.

INTRODUCTION: Over the past 50 years women and men have postponed family formation in high-income societies. Fertility assessment and counselling has been suggested as a method to reduce delayed childbearing and its consequences. This study explored women's perceptions of how attending a fertility assessment intervention influenced their decisions and choices regarding family formation and childbearing. MATERIAL AND METHODS: Follow-up data from a longitudinal semi-structured qualitative interview study including 20 women aged 35-40 years seeking individual fertility counselling at the Fertility Assessment and Counselling Clinic at Rigshospitalet, Copenhagen, Denmark. The interviews were conducted one year after their consultation. Data were analysed by qualitative content analysis. RESULTS: The women perceived an increase in their knowledge after they had attended the counselling. The women saw the counselling as a catalyst for change-they changed their behaviour and relationship status. The women stopped thinking about the pros and cons of childbearing and acted instead. The women did not experience any regrets about acting. Some of the women felt that they were still in limbo as they were still in doubt concerning childbearing. The consultation had not given them an answer with a clear deadline in terms of delaying attempts to become pregnant, and this frustrated them. CONCLUSIONS: Our study highlights the impact of a fertility assessment and counselling intervention which included a perceived increase in knowledge. The clinic allows for an individualized approach to fertility awareness which is necessary given the unique nature of childbearing decisions.

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.

Men's expectations and experiences of fertility awareness assessment and counseling.

INTRODUCTION: Men play an important role in couples' decisions about the timing of parenthood and they tend to delay parenthood. The reasons for delaying childbearing are multifaceted and complex. Their decisions may be based on a lack of accurate information about the reproductive life span and the consequences of delaying parenthood. The aim of this study was to explore men's expectations and experiences of fertility counseling. MATERIAL AND METHODS: Data were collected through semi-structured qualitative interviews with 21 men attending either the Fertility Assessment and Counseling Clinic in Copenhagen or in Horsens, Denmark. The men had no known fertility problems before going to the fertility counseling. They were interviewed before and after fertility counseling. RESULTS: The men were not concerned about their fertility before going to counseling. They believed they would be able to conceive whenever they wanted. Three of them had low semen quality and felt "punched in the gut" when they received these results at the fertility counseling. The study participants preferred clear and concrete information, and relevant knowledge at the right time was very important. The men felt empowered after the fertility counseling because they were equipped with concrete information that could inform their parenthood plans and decisions. Even the men who received unexpected bad news felt positive about the counseling. The participants perceived their knowledge and awareness of risk factors concerning fertility had increased. CONCLUSIONS: Men may benefit from an individualized approach where their fertility is assessed and they receive tailored fertility counseling specific to their personal fertility results. This type of intervention may be effective in increasing men's fertility awareness because it is personally relevant.

Low semen quality and experiences of masculinity and family building.

INTRODUCTION: Infertility is a concern for men and women. There is limited knowledge on how male factor infertility affects the couple in fertility treatment. The aim of this study was to explore how severe male factor infertility affects men's sense of masculinity, the couple's relationship and intentions about family formation. MATERIAL AND METHODS: Semi-structured qualitative interview study at the Fertility Clinic at Copenhagen University Hospital, Hvidovre, Denmark. Ten men with very poor semen quality initiating fertility treatment were interviewed between November 2014 and May 2015. Data were analyzed using qualitative content analysis. RESULTS: Three themes were identified: "Threatened masculinity", "Being the strong one: impact on the couple" and "Consideration of family building options: a chapter not willing to start". The men felt that they could not fulfill their role as a man. Some couples had conflicts and discussions because the women in general wanted to talk more about infertility than the men. The men focused on having a biological child. They wanted to focus on achieving biological parenthood and postpone consideration of other family building options such as adoption or the use of semen donation in order to become a parent. CONCLUSIONS: The consequence of severe male factor infertility was a threatened sense of masculinity. Fertility specialists and nurses should recognize the impact of male infertility and create space to give their patients an opportunity to verbalize their concerns and questions related to male factor infertility and the different challenges that the couple faces during the fertility treatment.

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.

When time runs out: reconciling permanent childlessness after delayed childbearing.

OBJECTIVE: This study aimed to examine the experience of permanent childlessness after delayed childbearing. BACKGROUND: More women are delaying childbearing while they pursue a career, gain financial stability and seek an appropriate partner. However, given that fertility declines with age, there is concern that more women will end up permanently, unintentionally childless after postponing childbearing. There is little known about this growing and invisible group. METHODS: An interpretive phenomenological analysis was used to conduct the study. A purposive sample of 15 women who identified as being permanently childless after delaying childbearing participated in the study. Data were collected using in-depth semi-structured interviews. RESULTS: Themes included feelings of grief, loss and isolation; a need to make sense of their childlessness; and a need to rebuild and refocus their lives and identities regardless of whether they had actually tried to conceive during their childbearing years. Women struggled with feelings of regret and the need to reconcile the reality of their choice to delay childbearing based on their values and beliefs about the ideal conditions within which to raise a child with feelings of powerlessness to pursue motherhood when they were likely still fertile. CONCLUSION: Women who are permanently childless after delaying childbearing experience similar feelings to those who are childless after infertility and failed fertility treatments regardless of whether they tried to conceive during their reproductive years. However, this group has unique needs based on their feelings of regret, powerlessness and responsibility for their childlessness.

The other side of the fertility coin: a comparison of childless men's and women's knowledge of fertility and assisted reproductive technology.

OBJECTIVE: To determine childless men's knowledge about fertility and assisted reproductive technology (ART) treatments and family building options, compared to knowledge of a sample of childless women. DESIGN: Self-report questionnaire comprising 2 self-ratings and 20 knowledge questions related to later childbearing and ART. SETTING: Online survey. PATIENT(S): A total of 599 presumed fertile, childless men between the ages of 20 and 50 years. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Knowledge of fertility and ART as measured by the male version of the Fertility Awareness Survey. RESULT(S): The majority of participants rated themselves as having some knowledge or being fairly knowledgeable about fertility and ART. However, on the 20 knowledge questions, overall knowledge was limited, with more than 50% of the sample answering correctly only 4 of 20 knowledge questions. The men demonstrated even less knowledge of fertility and ART than childless women. CONCLUSION(S): Given that the childless men in our study had no coherent body of knowledge regarding age-related fertility and ART treatment and family-building options, men may be contributing to the trend to delay childbearing. If they are to be effective in supporting informed fertility and childbearing decisions, education programs must target both women and men.