Survey shows that Swedish healthcare professionals have a positive attitude towards surrogacy but the health of the child is a concern.

AIM: In February 2016, Sweden upheld its ban on surrogacy following a Government enquiry. This survey investigated attitudes towards surrogacy among primary health professionals working with children and their experiences of working with families following surrogacy abroad. METHODS: From April to November 2016, nurses, physicians and psychologist working in primary child health care in four counties in Sweden were invited to participate in a cross-sectional online survey about surrogacy. RESULTS: The mean age of the 208 participants was 49.2 years (range 27-68) and nearly 91% were women. Approximately 60% supported legalised surrogacy. Wanting a conscience clause to be introduced in Sweden was associated with not supporting surrogacy for any groups, while personal experiences of infertility and clinical experiences with families following surrogacy were associated with positive attitudes towards surrogacy for heterosexual couples. The majority (64%) disagreed that surrogate children were as healthy as other children, and many believed that they risked worse mental health (21%) and social stigmatisation (21%). CONCLUSION: We found that 60% supported legalised surrogacy, but many expressed concerns about the children's health and greater knowledge about the medical and psychosocial consequences of surrogacy is needed.

Post-traumatic stress symptoms in Swedish obstetricians and midwives after severe obstetric events: a cross-sectional retrospective survey.

OBJECTIVE: To examine post-traumatic stress reactions among obstetricians and midwives, experiences of support and professional consequences after severe events in the labour ward. DESIGN: Cross-sectional online survey from January 7 to March 10, 2014. POPULATION: Members of the Swedish Society of Obstetrics and Gynaecology and the Swedish Association of Midwives. METHODS: Potentially traumatic events were defined as: the child died or was severely injured during delivery; maternal near-miss; maternal mortality; and other events such as violence or threat. The validated Screen Questionnaire Posttraumatic Stress Disorder (SQ-PTSD), based on DSM-IV (1994) 4th edition, was used to assess partial post-traumatic stress disorder (PTSD) and probable PTSD. MAIN OUTCOME MEASURES: Partial or probable PTSD. RESULTS: The response rate was 47% for obstetricians (n = 706) and 40% (n = 1459) for midwives. Eighty-four percent of the obstetricians and 71% of the midwives reported experiencing at least one severe event on the delivery ward. Fifteen percent of both professions reported symptoms indicative of partial PTSD, whereas 7% of the obstetricians and 5% of the midwives indicated symptoms fulfilling PTSD criteria. Having experienced emotions of guilt or perceived insufficient support from friends predicted a higher risk of suffering from partial or probable PTSD. Obstetricians and midwives with partial PTSD symptoms chose to change their work to outpatient care significantly more often than colleagues without these symptoms. CONCLUSIONS: A substantial proportion of obstetricians and midwives reported symptoms of partial or probable PTSD after severe traumatic events experienced on the labour ward. Support and resilience training could avoid suffering and consequences for professional carers. TWEETABLE ABSTRACT: In a survey 15% of Swedish obstetricians and midwives reported PTSD symptoms after their worst obstetric event.

It takes two to tango: information-sharing with offspring among heterosexual parents following identity-release sperm donation.

STUDY QUESTION: How do heterosexual parents reason about and experience information-sharing with offspring following identity-release sperm donation? SUMMARY ANSWER: Sharing information about using donor-conception with offspring is a complex process at several levels, with the parent's personal beliefs and the child's responses serving as driving or impeding forces for the information-sharing process. WHAT IS KNOWN ALREADY: The overall view of disclosure in gamete donation has shifted from secrecy to openness, but there is still uncertainty among parents concerning how and when to tell the child about his/her genetic origin. Most research on donor-conceived families has focused on donation treatment under anonymous or known circumstances, and there is a lack of studies in settings with identity-release donations. STUDY DESIGN, SIZE, DURATION: A qualitative interview study among 30 parents following identity-release sperm donation treatment. Interviews were conducted from February 2014 to March 2015. PARTICIPANTS/MATERIALS, SETTING, METHODS: The present study is part of the prospective longitudinal Swedish Study on Gamete Donation (SSGD), including all fertility clinics performing gamete donation in Sweden. A sample of participants in the SSGD, consisting of heterosexual parents with children aged 7-8 years following identity-release sperm donation, participated in individual semi-structured interviews. MAIN RESULTS AND THE ROLE OF CHANCE: The analysis revealed one main theme: information-sharing is a process, with three subthemes; (i) the parent as process manager, (ii) the child as force or friction and (iii) being in the process. The first two subthemes were viewed as being linked together and their content served as driving or impeding forces in the information-sharing process. LIMITATIONS, REASONS FOR CAUTION: The fact that the study was performed within the context of the Swedish legislation on identity-release donation must be taken into consideration as regards transferability to other populations, as this may affect parents' reasoning concerning their information-sharing with the child. WIDER IMPLICATIONS OF THE FINDINGS: The present findings highlight the role of the donor-conceived child in the information-sharing process and may contribute to develop counselling that increases parents' confidence in handling children's reactions to information about their genetic origin. STUDY FUNDING/COMPETING INTERESTS: Financial support from The Swedish Research Council, The Family Planning Fund in Uppsala and Ferring Pharmaceuticals. There are no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

Attitudes towards disclosure and relationship to donor offspring among a national cohort of identity-release oocyte and sperm donors.

STUDY QUESTION: What are oocyte donors and sperm donors' attitudes towards disclosure and relationship to donor offspring? SUMMARY ANSWER: Oocyte and sperm donors in an identity-release donor programme support disclosure to donor offspring and have overall positive or neutral attitudes towards future contact with offspring. WHAT IS KNOWN ALREADY: There is a global trend towards open-identity gamete donation with an increasing number of countries introducing legislation allowing only identifiable donors. While women and men who enrol in identity-release donor programmes accept that they may be contacted by donor offspring, there is limited knowledge of their attitudes towards disclosure to donor offspring and how they perceive their relationship to potential donor offspring. STUDY DESIGN, SIZE AND DURATION: The present study is part of the 'Swedish study on gamete donation', a prospective cohort study including donors at all fertility clinics performing donation treatment in Sweden. During a 3-year period (2005-2008), donors were recruited consecutively and a total of 157 oocyte donors and 113 sperm donors (who did not donate to a specific 'known' couple) were included prior to donation. Participants in the present study include 125 female (80%) and 80 male donors (71%) that completed two follow-up assessments. PARTICIPANTS/MATERIALS, SETTINGS AND METHODS: Participants completed two postal questionnaires 2 months after donation and 14 months after donation. Attitudes towards disclosure to donor offspring were assessed with an established instrument. Perceptions of involvement with donor offspring and need for counselling was assessed with study-specific instruments. Statistical analyses were performed with non-parametric tests. MAIN RESULTS AND THE ROLE OF CHANCE: A majority of oocyte and sperm donors supported disclosure to donor offspring (71-91%) and had positive or neutral attitudes towards future contact with offspring (80-87%). Sperm donors reported a higher level of involvement with potential donor offspring compared with oocyte donors (P = 0.005). Few donors reported a need for more counselling regarding the consequences of their donation. LIMITATIONS, REASONS FOR CAUTION: While the multicentre study design strengthens external validity, attrition induced a risk of selection bias. In addition, the use of study-specific instruments that have not been psychometrically tested is a limitation. WIDER IMPLICATIONS OF THE FINDINGS: The positive attitudes towards disclosure to offspring of female and male identity-release donors are in line with previous reports of anonymous and known donors. While our results on donors' general positive or neutral attitudes towards future contact with potential donor offspring are reassuring, a subset of donors with negative attitudes towards such contact warrants concern and suggests a need for counselling on long-term consequences of donating gametes. STUDY FUNDING: The 'Swedish study on gamete donation' was funded by the Swedish Research Council, the Swedish Council for Health, Working Life and Welfare, and the Regional Research Council in Uppsala-Örebro. There are no conflicts of interest to declare.

Folic acid supplementation and IVF pregnancy outcome in women with unexplained infertility.

Folic acid supplements are commonly used by infertile women which leads to a positive folate status. However, the effect of folic acid supplements on pregnancy outcome in women with unexplained infertility has not been well investigated. This study evaluated folic acid supplement use and folate status in women with unexplained infertility in relation to IVF pregnancy outcome. In addition, use of folic acid supplements and folate status were compared between women with unexplained infertility and fertile, nonpregnant control women. Women with unexplained infertility used significantly more folic acid supplements and had higher median total folic acid intake from supplements compared with fertile control women (both P < 0.001). Women with unexplained infertility also had significantly higher median plasma folate and lower median plasma homocysteine concentrations than fertile women (both P < 0.001), but folic acid supplementation or folate status were not related to pregnancy outcome in women with unexplained infertility. In conclusion, folic acid supplementation or good folate status did not have a positive effect on pregnancy outcome following infertility treatment in women with unexplained infertility. Folate is one of the B vitamins which has been suggested to be related to infertility. Folic acid is an artificial form of folate which is commonly used in dietary supplements. Folic acid supplementation has been shown to increase folate concentrations and decrease concentrations of the amino acid homocysteine in the blood. Folic acid supplementation is commonly used by infertile women, but the effect on pregnancy outcome in women with a diagnosis of unexplained infertility has not been thoroughly investigated. In the present study, folic acid supplement use and folate status (concentrations of folate and homocysteine) in women with unexplained infertility were evaluated in relation to pregnancy outcome. In addition, the use of folic acid supplements and folate status were compared between women with unexplained infertility and fertile control women. Our results showed that women with unexplained infertility used considerably more folic acid supplements and had higher total folic acid intake from supplements compared with fertile control women. Women with unexplained infertility had better blood folate and homocysteine concentrations than fertile women, but folic acid supplementation or folate status were not related to pregnancy outcome following the infertility treatment. In conclusion, high folic acid intake or good folate status did not increase the possibility of a birth of a healthy baby after infertility treatment in women with unexplained infertility.

How do lesbian couples compare with heterosexual in vitro fertilization and spontaneously pregnant couples when it comes to parenting stress?

AIM: To study parenting stress in lesbian parents and to compare that stress with heterosexual parents following in vitro fertilisation (IVF) or spontaneous pregnancies. METHODS: This survey took place during 2005-2008 and was part of the Swedish multicentre study on gamete donation. It comprised 131 lesbian parents, 83 heterosexual IVF parents, who used their own gametes, and 118 spontaneous pregnancy parents. The participants responded to the questionnaire when the child was between 12 and 36-months-old and parenting stress was measured by the Swedish Parenting Stress Questionnaire (SPSQ). RESULTS: Lesbian parents experienced less parenting stress than heterosexual IVF parents when it came to the General Parenting Stress measure (p = 0.001) and the subareas of Incompetence (p < 0.001), Social Isolation (p = 0.033) and Role Restriction (p = 0.004). They also experienced less parenting stress than heterosexual spontaneous pregnancy couples, according to the Social Isolation subarea (p = 0.003). Birth mothers experienced higher stress than co-mothers and fathers, according to the Role Restriction measure (p = 0.041). CONCLUSION: These are reassuring findings, considering the known challenges that lesbian families face in establishing their parental roles and, in particular, the challenges related to the lack of recognition of the co-mother.

Sexual orientation of women does not affect outcome of fertility treatment with donated sperm.

STUDY QUESTION: Is there a difference in fertility between heterosexual women and lesbians undergoing sperm donation? SUMMARY ANSWER: Women undergoing treatment with donated sperm are equally fertile regardless of sexual orientation. WHAT IS KNOWN ALREADY: Lesbians have an increased prevalence of smoking, obesity, sexually transmitted diseases and, possibly, polycystic ovary syndrome, all factors known to affect fertility. Previous studies on sperm donation inseminations (D-IUI) show conflicting results regarding pregnancy outcome. STUDY DESIGN, SIZE, DURATION: This is a national study of 171 lesbians and 124 heterosexual women undergoing sperm donation both as D-IUI (lesbian n = 438, heterosexual n = 298) and as embryo transfers (ET) after IVF with donated sperm (lesbians n = 225, heterosexuals n = 230) during 2005-2010. PARTICIPANTS/MATERIALS, SETTING, METHODS: All clinics in Sweden offering sperm donation recruited patients. Differences in patients' medical history, treatment results and number of treatments to live birth were analyzed using independent samples t-test, Pearson's χ(2) test or Fisher's exact probability test. MAIN RESULTS AND THE ROLE OF CHANCE: 71.8% of heterosexuals and 69.0% of lesbians had a child after treatment. The mean number of treatments was 4.2 for heterosexual women and 3.9 for lesbians. The total live birth rate, regardless of treatment type, was 19.7% for heterosexuals and 19.5% for lesbians. For D-IUI, the live birth rate was 12.8% for heterosexuals and 16.0% for lesbians and the live birth rate for all IVF embryo transfers (fresh and thawed cycles) was 28.7% for heterosexuals and 26.2% for lesbians. There were no differences in live birth rate between the groups for each of the different types of insemination stimulations (natural cycle; clomiphene citrate; FSH; clomiphene citrate and FSH combined). Nor was there a difference in live birth rate between the groups for either fresh or thawed embryo transfer. There was no difference between the proportions of women in either group or the number of treatments needed to achieve a live birth. Heterosexuals had a higher prevalence of smokers (9.2%), uterine polyps (7.2%) or previous children (11.3%) than lesbians (smokers 2.8%, P = 0.03; polyps 1.8%, P = 0.03; child 2.5%, P = 0.003). LIMITATIONS, REASONS FOR CAUTION: This study is limited to women living in stable relationships undergoing treatment with donated sperm in a clinical setting and may not apply to single women or those undergoing home inseminations. WIDER IMPLICATIONS OF THE FINDINGS: These results may influence healthcare policy decisions as well as increase the quality of clinical care and medical knowledge of healthcare professionals. The data also have important implications for individuals regarding screening, infertility diagnostic procedures and treatment types offered to heterosexuals and lesbians seeking pregnancy through sperm donation. STUDY FUNDING/COMPETING INTEREST(S): Funding was granted by the Stiftelsen Familjeplaneringsfonden i Uppsala; the Swedish Research Council for Health, Working Life and Welfare; and the Marianne and Marcus Wallenberg Foundation. The authors report no conflicts of interest.

Attitudes towards embryo donation among infertile couples with frozen embryos.

STUDY QUESTION: What are the attitudes towards different aspects of embryo donation among Swedish infertile couples who have surplus cryopreserved embryos? SUMMARY ANSWER: Nearly three-quarters of infertile couples with surplus embryos were in favour of embryo donation. A majority of respondents were also in favour of embryos being donated for research. WHAT IS KNOWN ALREADY: Currently, embryo donation to other infertile couples is prohibited by law in Sweden. Encouraging results have been published from countries allowing embryo donation, although it is a complex procedure associated with many emotional, ethical, legal and psychosocial aspects. STUDY DESIGN, SIZE, DURATION: This cross-sectional study included 471 infertile couples (942 patients) treated during the period March 2006 to March 2009. PARTICIPANTS/MATERIALS, SETTING, METHODS: Infertile couples who had been treated at a Swedish university-based hospital and private IVF clinic and who had cryopreserved embryos were sent questionnaires with questions regarding socio-demographic data and their attitudes towards embryo donation. MAIN RESULTS AND THE ROLE OF CHANCE: The response rate to the questionnaire was 58%. Of the respondents, 76% supported the donation of surplus embryos to other infertile couples, but there were divided opinions regarding the disclosure of the genetic parents' identities. Close to 60% of the participants indicated that donations of embryos should be allowed for research and about 45% of the participants approved donations of embryos to single women. LIMITATIONS, REASONS FOR CAUTION: The relatively low response rate and the hypothetical nature of the questions may limit the validity of the results. WIDER IMPLICATIONS OF THE FINDINGS: The results from the study indicate that cryopreserved embryos may be available for donation to other infertile couples, particularly where restrictions can be set on recipient characteristics.

Disclosure behaviour and intentions among 111 couples following treatment with oocytes or sperm from identity-release donors: follow-up at offspring age 1-4 years.

STUDY QUESTION: Do heterosexual parents of young children following oocyte donation (OD) and sperm donation (SD) tell or intend to tell their offspring about the way he/she was conceived? SUMMARY ANSWER: Following successful treatment with oocytes or sperm from identity-release donors in Sweden, almost all heterosexual couples intend to tell their offspring about the way he/she was conceived and some start the information-sharing process very early. WHAT IS KNOWN AND WHAT THIS PAPER ADDS: Although the Swedish legislation on identity-release gamete donors has been in effect since 1985, there is a discrepancy between the behaviour of donor-insemination parents and the legal intention that offspring be informed about their genetic origin. The present study contributes data on a relatively large sample of oocyte and sperm recipient couples' intended compliance with the Swedish legislation. DESIGN AND DATA COLLECTION METHOD: The present study constitutes a follow-up assessment of heterosexual couples who had given birth to a child following treatment with donated oocytes. Data collection was performed during 2007-2011; participants individually completed a questionnaire when the child was between 1 and 4 years of age. PARTICIPANTS AND SETTING: The present study is part of the Swedish Study on Gamete Donation, a prospective longitudinal cohort study including all fertility clinics performing gamete donation in Sweden. For children conceived via OD, 107 individuals (including 52 couples and 3 individuals) agreed to participate (73% response). For children conceived via SD, the response rate was 70% (n = 122 individuals, including 59 couples and 4 individuals). Mean age of participants was 34 years (SD 4.4) and they reported a high level of education. MAIN RESULTS: The majority of participants (78%) planned to tell the child about the donation, 16% had already started the information-sharing process and 6% planned not to tell their child about the donation or were undecided. Many were unsure about a suitable time to start the disclosure process and desired more information about strategies and tools for information sharing. Agreement on disclosure to offspring within the couple was related to the quality of the partner relationship. BIAS AND GENERALIZABILITY: There is a risk of selection bias, with gamete recipients preferring secrecy and non-disclosure declining study participation. The results may be regarded as partly generalizable to heterosexual couples with young children following treatment with gametes from legislatively mandated identity-release donors in an established donor programme. STUDY FUNDING/COMPETING INTERESTS: Study funding by Merck Serono, The Swedish Research Council and The Family Planning Fund in Uppsala. No conflicts of interest to declare.

Who becomes a sperm donor: personality characteristics in a national sample of identifiable donors.

OBJECTIVE: To study the personality characteristics of identifiable sperm donors in a national sample in comparison with the same characteristics of a control group. DESIGN: Descriptive study. SETTING: All clinics (n=7) performing gamete donation in Sweden. POPULATION: All Swedish sperm donors recruited during 2005-08. An age-matched group of Swedish men served as controls. METHODS: Standardised questionnaires were used to measure personality. MAIN OUTCOME MEASURES: Demographics and the Temperament and Character Inventory (TCI). RESULTS: The mean age of the donors was 33.8±7.8 years (18-56 years). About one-third (36.5%) of the donors had biological children of their own. With regard to personality, significant differences were present on harm avoidance, with lower means for sperm donors (P=0.002, 95% CI -3.74 to -0.85), and on self-directedness and cooperativeness, with higher means for donors (P=0.002, 95% CI 0.97-4.19; P=0.001; 95% CI 0.75-2.95, respectively), compared with controls. This indicates that the donors in general feel less worried and suffer less from uncertainty, shyness and fatigability than controls. They also perceive themselves as being autonomous, with a capacity to take responsibility, to behave in a goal-directed manner, to be resourceful and self-acceptant, and to behave in a manner guided by meaningful values and goals. Furthermore, they describe themselves as being well integrated in humanity or society, and having a good capacity for identification with and acceptance of other people. CONCLUSIONS: The screening process at the clinics seems to generate a group of stable, mature and well-integrated donors, and this is a promising result for the future.

Two decades after legislation on identifiable donors in Sweden: are recipient couples ready to be open about using gamete donation?

BACKGROUND Two decades after the introduction of Swedish legislation that allows children born as a result of gamete donation access to identifying information about the donor, a nationwide multicentre study on the psychosocial consequences of this legislation for recipients and donors of gametes was initiated in 2005. The aim of the present study was to investigate recipient couples' attitudes and behaviour regarding disclosure to offspring and others, attitudes towards genetic parenthood and perceptions of information regarding parenthood after donation. METHODS The present study is part of the prospective longitudinal 'Swedish study on gamete donation', including all fertility clinics performing donation treatment in Sweden. A consecutive cohort of 152 heterosexual recipient couples of donated oocytes (72% response) and 127 heterosexual recipient couples of donated sperm (81% response) accepted participation in the study. In connection with the donation treatment, male and female participants individually completed two questionnaires with study-specific instruments concerning disclosure, genetic parenthood and informational aspects. RESULTS About 90% of participants (in couples receiving anonymous donated gametes) supported disclosure and openness to the offspring concerning his/her genetic origin. Only 6% of all participants had not told other people about their donation treatment. Between 26 and 40% of participants wanted additional information/support about parenthood following donation treatment. CONCLUSIONS Two decades after the Swedish legislation of identifiable gamete donors, recipient couples of anonymously donated sperm and oocytes are relatively open about their treatment and support disclosure to offspring. Recipient couples may benefit from more information and support regarding parenthood after gamete donation. Further studies are required to follow-up on the future parents' actual disclosure behaviour directed to offspring.

Prevalence of psychiatric disorders in infertile women and men undergoing in vitro fertilization treatment.

BACKGROUND: This study was undertaken to determine the prevalence of psychiatric disorders in infertile women and men undergoing in vitro fertilization (IVF) treatment. METHODS: Participants were 1090 consecutive women and men, 545 couples, attending a fertility clinic in Sweden during a two-year period. The Primary Care Evaluation of Mental Disorders (PRIME-MD), based on the Diagnostic and Statistical Manual of Mental Disorders, 4th edn (DSM-IV), was used as the diagnostic tool for evaluating mood and anxiety disorders. RESULTS: Overall, 862 (79.1%) subjects filled in the PRIME-MD patient questionnaire. Any psychiatric diagnosis was present in 30.8% of females and in 10.2% of males in the study sample. Any mood disorder was present in 26.2% of females and 9.2% of males. Major depression was the most common mood disorder, prevalent in 10.9% of females and 5.1% of males. Any anxiety disorder was encountered in 14.8% of females and 4.9% males. Only 21% of the subjects with a psychiatric disorder according to DSM-IV received some form of treatment. CONCLUSIONS: Mood disorders are common in both women and men undergoing IVF treatment. The majority of subjects with a psychiatric disorder were undiagnosed and untreated.

Gender differences in psychological reactions to infertility among couples seeking IVF- and ICSI-treatment.

BACKGROUND: Gender differences and similarities in psychological reactions related to infertility, perception of social support, the effect of infertility on the marital relationship and coping-style were investigated among Swedish couples seeking in vitro fertilization -- or intracytoplasmic sperm injection - treatment. METHODS: Ninety-one couples entering treatment completed the Infertility Reaction Scale, a self-report questionnaire with structured and open-ended questions and the Miller Behavioral Style Scale. RESULTS: The women reacted more strongly to their infertility than the men as measured by the Infertility Reaction Scale (p<0.05). Factor analysis of the Infertility Reaction Scale produced three factors for men and women respectively. The first factor that emerged for the men was 'The male role and social pressure' and the second factor was 'The major focus of life'. For the women the two first factors were reversed compared to those of the men. The third factor 'Effect on sexual life' was similar for men and women. Significantly more men than women had not confided in anyone about their infertility problem (p<0.001). The information-seeking coping style was significantly correlated with infertility distress only among men (p

Psychological reactions during in-vitro fertilization: similar response pattern in husbands and wives.

The purpose of this study was to examine differences in daily emotional, physical and social reactions among husbands and wives during in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). Forty couples about to undergo ICSI or IVF at a private infertility clinic monitored their emotional, physical and social reactions daily for one complete treatment cycle from the first day of stimulation until the outcome of treatment was known (approximately 35 days). The results showed that men and women had a similar response pattern to oocyte retrieval, fertilization, embryo transfer and the pregnancy test. These stages were associated with the most significant changes in reactions for both spouses. The pattern of results suggested that the most important psychological determinant of reactions during IVF was the uncertainty of treatment procedures. Spouses appeared to be equally sensitive to this uncertainty and both appeared to respond to it with ambivalent feelings involving emotional distress and positive feelings of hope and intimacy.