Sofia Gameiro

Why we should talk about compliance with assisted reproductive technologies (ART): a systematic review and meta-analysis of ART compliance rates

BACKGROUND The goal of this systematic review and meta-analysis was to estimate the rate of compliance with assisted reproductive technologies (ART) and examine its relationship with treatment success rates. METHODS Six databases were systematically searched from 1978 to December 2011. Studies were included if they reported data on patient progression through three consecutive standard ART cycles. Compliance was estimated for the first three ART cycles (typical ART Regimen Compliance, TARC) and after the first and the second failed cycles (CAF1, CAF2). Treatment success rates for all patients who started ART and for those who fully complied with the three ART cycles were estimated. RESULTS Ten studies with data for 14 810 patients were included. TARC was 78.2% [95% confidence interval (CI) 68.8–85.3%], CAF1 was 81.8% (73.3–88.1%) and CAF2 was 75.3% (68.2–81.2%). The overall success rate was 42.7% (32.6–53.6%) for all patients starting ART and 57.9% (49.4–65.9%) for those who complied with three ART cycles. Compliance rates did not vary according to study quality, but TARC was higher for studies that reported data on doctor-censored patients versus those that did not (84.2% 95% CI 75.5–90.2 versus 70.6% 95% CI 58.3–80.5, P = 0.043). Analysis of funnel plots and the Egger test indicated publication bias for CAF1. CONCLUSIONS Findings from this meta-analysis should reassure clinics and patients that most patients are able to comply with three cycles of ART. Compliers could increase their chances of success by as much as 15%. A more detailed assessment of compliance requires monitoring long-term treatment trajectories through the creation of national registries.

Maternal adjustment to the birth of a child: Primiparity versus multiparity

Introduction: The literature has highlighted the birth of a first child as a crisis moment that implies change and reorganisation. None the less, the specificities of maternal adjustment to the birth of another child are not yet completely known. Goals: To understand differences in adjusting to the birth of a child, in primiparous and multiparous mothers. Specifically: (1) identify and describe differences in adjusting at two different moments: 2–5 days after the birth and 8 months post‐partum; (2) identify and describe differences or continuities among primiparous and multiparous mothers regarding the temporal evolution of adjustment. Method: 179 mothers (98 primiparous; 81 multiparous) were assessed in two different periods: 2–5 days after the birth and 8 months later, concerning adjustment and need for reorganisation. The assessment protocol included a social‐demographic data file, the Emotional Assessment Scale, the Brief Symptom Inventory, the Perceived Stress Scale, and adjectival scales. Results: Primiparous mothers report greater adjustment difficulties right after the birth. Multiparous mothers show a less positive adjustment trajectory, mainly reflected in increasing levels of negative emotional reactivity. Conclusion: Results support the existence of different adjustment trajectories for primiparous and multiparous mothers, suggesting the need for differentiated psychological intervention strategies regarding each group.

Development and psychometric properties of the World Health Organization Quality of Life Assessment Instrument (WHOQOL-100) in Portugal.

BackgroundAt the beginning of the 1990s, the World Health Organization (WHO) developed a project in order to create a cross-cultural instrument of quality of life assessment: the World Health Organization Quality of Life (WHOQOL).PurposeThis paper describes the development of the European Portuguese version of the WHOQOL-100, according to the methodology recommended by the WHO.MethodSpecial attention is given to the qualitative pilot study, which led to the development of the Portuguese Facet [Political P], and to the empirical pilot study and the psychometric studies, based on the application of the Portuguese version of the instrument to a sample of 315 subjects from the general population and 289 patients. The assessment protocol also included the Beck Depression Inventory and the Brief Symptom Inventory.ResultsThe Portuguese version of WHOQOL-100 showed acceptable internal consistency (α range 0.84–0.94) and test–retest reliability in all domains (r range 0.67–0.86). Discriminant validity was significant for all domains, except in Spirituality. Convergent validity with the Beck Depression Inventory and the Brief Symptom Inventory was satisfactory for most domains.ConclusionThe WHOQOL showed good psychometric characteristics, suggesting that the Portuguese version of WHOQOL is valid and reliable in the assessment of quality of life in Portugal.

Psychosocial adjustment during the transition to parenthood of Portuguese couples who conceived spontaneously or through assisted reproductive technologies.

We examined the psychosocial adjustment of 35 Portuguese couples who conceived through Assisted Reproductive Technologies (ART) and 31 couples with a spontaneous conception during their transition to parenthood (pregnancy and 4 months postpartum). Couples completed self-report questionnaires regarding their perceptions of pregnancy and parenthood, psychological distress, quality of life, marital relationship, and parenting stress. Compared with parents who conceived spontaneously, parents who conceived through ART perceived pregnancy as being more risky and demanding, reported a decrease in their psychological quality of life, and ART fathers only perceived themselves as being more competent than fathers who conceived spontaneously. Healthcare professionals should be aware of need of couples in their efforts to adapt to the individual and relational challenges associated with the transition to parenthood.

The indirect effect of contextual factors on the emotional distress of infertile couples

Few studies were dedicated to study the role of contextual factors, such as the socioeconomic status and urban or rural residence in emotional distress of infertile couples. This study aimed to explore the impact of contextual factors on emotional distress, either directly or by affecting the importance of parenthood in ones life, which in turn affects emotional distress. In this cross-sectional study, 70 couples recruited during hormonal stimulation phase prior to in vitro fertilisation completed clinical and sociodemographic forms and self-report questionnaires assessing representations about the importance of parenthood and emotional distress. Path analysis using structural equation modelling was used to examine direct and indirect effects among variables. Results indicated that socioeconomic status and place of residence had an impact in emotional distress by affecting the representations about the importance of parenthood in ones life. Gender differences were found regarding model paths, suggesting that the social context may have a stronger influence on womens emotional distress than on their partners’ distress. When delineating psychological interventions, health care providers should consider that cultural values about children and parenthood contribute to shape the infertility experience.

Women's intentions to use fertility preservation to prevent age-related fertility decline

The optimal age to cryopreserve oocytes for later use is before 36 years. Current users are on average 38 years old. In this cross-sectional study an online survey was constructed about the factors associated with the intentions of childless women aged 28-35 years to use fertility preservation (FP). Questions were derived from the Theory of Planned Behaviour (attitudes and subjective norms regarding FP and perceived behaviour control to do FP) and the Health Belief Model (perceived susceptibility of infertility, perceived severity of childlessness, barriers and benefits of FP and cue to use FP). Also addressed were parenthood goals, fertility knowledge and intentions to use FP within 2 years. The data were analysed using structural equation modelling. The Health Belief Model showed a good fit to the data (χ(2) [14, n = 257] = 13.63, P = 0.477; CFI = 1.000: RMSEA = 00, 90% CI [0.00-0.06]). Higher intentions to use FP were associated with feeling susceptible to infertility, considering FP useful to achieve parenthood, perceiving the implications of infertility as severe, expecting to have children at a later age and having fewer ethical concerns. This suggests an increase of fertility awareness is necessary for the optimal use of FP.

Changes in marital congruence and quality of life across the transition to parenthood in couples who conceived spontaneously or with assisted reproductive technologies

OBJECTIVE To investigate the relationship between changes in marital congruence (ie, level of agreement between partners about their relationship) and quality of life across the transition to parenthood in couples who conceived spontaneously and with assisted reproduction technology (ART). DESIGN Prospective longitudinal cohort design using multilevel modeling. SETTING Portuguese large public university-based hospital. PATIENT(S) Pregnant couples who conceived spontaneously and with ART. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) ENRICH Marital Inventory and the World Health Organization Brief Quality of Life Instrument. RESULT(S) For all couples, an increase in satisfaction with the marital relationship was associated with increases in all quality of life domains. For couples who conceived with ART only, a decrease from pregnancy to the postpartum period in congruence about the existence of conflicts in their relationship was associated with a decrease in psychologic quality of life. CONCLUSION(S) Couples who conceive with ART are usually satisfied with their marital relationship, but they may still disagree in their perceptions of this relationship, which may negatively impact their well-being. These results reinforce the role of couple-based interventions to prevent intracouple disagreement across the transition to parenthood, especially when conception is achieved with ART.

Are patients at risk for psychological maladjustment during fertility treatment less willing to comply with treatment? Results from the Portuguese validation of the SCREENIVF

STUDY QUESTION Do patients at risk for psychological maladjustment during fertility treatment present lower intentions to comply with recommended treatment than patients not at risk? SUMMARY ANSWER Patients at risk of psychological maladjustment present similar high intentions to comply with recommended fertility treatment to those not at risk but their intentions are conditioned by the degree of control they perceive over their fertility and its treatment and their capacity to accept a future without biological children. WHAT IS KNOWN ALREADY Infertile couples refer to the psychological burden of treatment as one of the most important reasons for withdrawal from recommended treatment. The SCREENIVF can be used before treatment to screen patients at risk for psychological maladjustment by assessing five risk factors: anxiety, depression, helplessness and lack of acceptance cognitions and social support. STUDY DESIGN, SIZE, DURATION Cross-sectional study. First, we investigated the psychometric properties of the Portuguese version of the SCREENIVF. Secondly, we investigated associations between risk for psychological maladjustment and intentions to comply with treatment. PARTICIPANTS/ MATERIALS, SETTING, METHODS Two hundred and ninety-one women and 92 men undergoing any stage of fertility treatment at Portuguese infertility clinics were recruited online or in the clinical setting (55% response rate). Participants completed questionnaires that assessed their emotional adjustment, quality of life and compliance intentions. MAIN RESULTS AND ROLE OF CHANCE The confirmatory factor analysis for the SCREENIVF indicated good fit [χ(2) = 188.50, P < 0.001; comparative fit index = 0.97; root-mean-square error of approximation = 0.06 (90% CI 0.05-0.07)] and all dimensions were reliable (α ≥ 0.70, except depression for men: α = 0.66). Fifty-two percent of women and 30% of men were at risk for maladjustment. Women and men at risk and not at risk for maladjustment reported similar intentions to comply with treatment (P > 0.05). Cognitive risk factors moderated negative associations found between distress and compliance intentions. Higher anxiety was associated with lower compliance intentions for patients with lower helplessness cognitions (β = -0.45, P = 0.01) and men with higher acceptance cognitions (β = -0.60; P = 0.03), but not for patients with higher helplessness cognitions (β = 0.25, P = 0.13) and men with lower acceptance cognitions (β = 0.38; P = 0.21). Higher depression was associated with lower compliance intentions for patients with higher helplessness cognitions (β = -0.33, P = 0.02), but not for patients with lower helplessness cognitions (β = 0.19, P = 0.30). LIMITATIONS, REASONS FOR CAUTION Few men participated and thus only medium-to-large effect sizes could be detected for them. Forty-eight percent of participants were recruited online and this could have resulted in higher rates of patients at risk. WIDER IMPLICATIONS OF THE FINDINGS The SCREENIVF is not useful to identify patients at risk for non-compliance. However, the clinic staff should be aware that patients who score high on helplessness cognitions and low on acceptance may need additional decisional aid to make autonomous and satisfying decisions about uptake of treatment. The Portuguese version of the SCREENIVF is valid and reliable and can be used with women undergoing any type of fertility treatment. STUDY FUNDING/ COMPETING INTEREST(S) S.G. received a postdoctoral fellowship from the Portuguese Foundation for Science and Technology (FCT-SFRH/BPD/63063/2009). There are no conflicts of interest to declare.

Evolution of psychology and counseling in infertility

Five key paradigm shifts are described to illustrate the evolution of psychology and counseling in infertility. The first paradigm shift was in the 1930s when psychosomatic concepts were introduced in obstetrics and gynecology as causal factors to explain why some couples could not conceive despite the absence of organic pathology. In the second shift, the nurse advocacy movement of the 1970s stimulated the investigation of the psychosocial consequences of infertility and promoted counseling to help couples grieve childlessness when medical treatments often could not help them conceive. The third shift occurred with the advent of IVF, which created a demand for mental health professionals in fertility clinics. Mental health professionals assessed the ability of couples to withstand the demands of this new high technology treatment as well as their suitability as potential parents. The fourth shift, in the 1990s, saw reproductive medicine embrace the principles of evidence-based medicine, which introduced a much more rigorous approach to medical practice (effectiveness and safety) that extended to psychosocial interventions. The most recent paradigm shift, in the new millennium, occurred with the realization that compliance with protracted fertility treatment depended on the adoption of an integrated approach to fertility care. An integrated approach could reduce treatment burden arising from multiple sources (i.e., patient, clinic, and treatment). This review describes these paradigm shifts and reflects on future clinical and research directions for mental health professionals.

Network support and parenting in mothers and fathers who conceived spontaneously or through assisted reproduction

Background: Little is known about the contribution of other significant relationships beyond the partnership for parental adjustment and care in parents who conceived through Assisted Reproductive Technologies (ART). Objective: This study examined the role of perceived network support on parenting stress and investment in the child in parents who conceived spontaneously or through ART, during their transition to parenthood. Methods: Thirty‐five couples who conceived through ART and 31 couples who conceived spontaneously completed self‐report questionnaires regarding perceived emotional and instrumental support from their social network members (i.e. nuclear and extended family members and friends) during pregnancy (twenty‐fourth week) and regarding parenting stress and investment in the child four months after the partum. Results: Regardless of method‐of‐conception, instrumental support from the nuclear family was positively associated with maternal investment in the child and emotional and instrumental support from the extended family were positively associated with paternal stress while support from friends was negatively associated with it. Conclusion: Results suggest that parents who conceive through ART and spontaneously are alike in that their adjustment to parenthood and the quality of the care they provide to their children depends on perceived support from nuclear and extended family and friends.