Physicians underestimate the importance of patient-centredness to patients: a discrete choice experiment in fertility care

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Inge W.H. van Empel1,*†, Eline A.F. Dancet1,2,3,†, Xander H.E. Koolman4, Willianne L.D.M. Nelen1, Elly A. Stolk5, Walter Sermeus3, Thomas M. D'Hooghe2 and Jan A.M. Kremer1

1Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands

2Leuven University Fertility Centre, Leuven University Hospital, Leuven, Belgium

3Centre for Health Services & Nursing Research, Catholic University Leuven, Brussels, Belgium

4IPSE studies, Delft University of Technology, Delft, The Netherlands

5Department of Health Policy & Management, Erasmus Medical Centre, Rotterdam, The Netherlands *Correspondence address. E-mail: i.vanempel{at}obgyn.umcn.nl?† These authors contributed equally to this work.

Received September 17, 2010. Revision received December 6, 2010. Accepted December 13, 2010. BACKGROUND High-quality healthcare should be effective, safe and patient-centred. How important patient-centredness is in relation to effectiveness of fertility care has never been investigated. This study aimed to determine and compare the importance of patient-centredness, relative to pregnancy rates, to patients and physicians.

METHODS A discrete choice experiment (DCE) was designed. Participants had to choose between hypothetical fertility clinics differing in following attributes: travel time; pregnancy rate (effectiveness); physicians' attitude; information on treatment; and continuity of physicians (the latter three represent patient-centredness). A total of 1378 patients and 268 physicians from eight Dutch and Belgian fertility clinics received the DCE-questionnaire. The attributes' relative importance was analysed using multinomial logistic regression. Additionally, patients' actual choice behaviour was investigated.

RESULTS In total, 925 patients and 227 physicians participated. Pregnancy rates were relatively more important to physicians. Patients assigned more value to patient-centredness (P< 0.001) and were willing to trade-off a higher pregnancy rate for patient-centredness than physicians recommended them to do (P< 0.05). For example, patients considered pregnancy rates 1.5 times as important as an interested physician's attitude, whereas physicians considered this 2.4 times as important (P< 0.001). The willingness to trade-off pregnancy rate for this attitude was 9.8% for patients and 6.3% for physicians (P< 0.001). A lack of patient-centredness was the most cited non-medical reason for changing fertility clinics.

CONCLUSIONS Patients and physicians put considerable value on pregnancy rates. However, physicians significantly undervalue the importance of patient-centredness to patients. Clinics aiming to optimize the quality of their services should be aware of the substantial importance their patients assign to patient-centredness.

© The Author 2011. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com This ArticleHum. Reprod. (2011) 26 (3): 584-593. doi: 10.1093/humrep/deq389 First published online: January 12, 2011

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Reduced plasma fibrinolytic potential in patients with recurrent implantation failure after IVF and embryo transfer

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M. Angeles Martínez-Zamora1, Montserrat Creus1, Dolors Tassies2, Juan Carlos Reverter2, Salvadora Civico1, Francisco Carmona1 and Juan Balasch1,*

1Institut Clínic of Gynecology, Obstetrics and Neonatology, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain

2Hemotherapy and Hemostasis Unit, Faculty of Medicine-University of Barcelona, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain *Correspondence address. Tel: +34-932275436; Fax: +34-932279325; E-mail: jbalasch{at}ub.eduReceived September 18, 2010. Revision received October 21, 2010. Accepted November 26, 2010. BACKGROUND Recurrent implantation failure (RIF) following embryo transfer (ET) is a major continuing problem in IVF. Women with haemostatic defects may be at increased risk of miscarriage and preclinical pregnancy loss. The fibrinolytic system is considered, at present, the key to new thrombotic pathogenic mechanisms. Patients with unexplained recurrent miscarriage have an impairment of fibrinolysis, as demonstrated by prolonged clot lysis time (CLT) in association with increased plasma levels of thrombin-activatable fibrinolysis inhibitor (TAFI). In this study, we investigated fibrinolytic potential in patients with RIF.

METHODS Three groups of patients were studied: 30 women with RIF (RIF group), 60 patients undergoing a first successful IVF–ET cycle (IVF group) and 60 healthy fertile women (FER group). Plasma CLT was measured using a global fibrinolysis assay. TAFI antigen plasma levels and polymorphisms in the TAFI gene (+505A/G and +1542C/G) were analysed using enzyme-linked immunosorbent assay and allele-specific PCR, respectively.

RESULTS CLT was significantly longer (P< 0.0001 and P< 0.0009, respectively) and TAFI antigen levels were significantly higher (both P< 0.0001) in the RIF versus the IVF and FER groups. A direct relationship between CLT and TAFI antigen levels (r = 0.40; P = 0.001) was detected in the whole study population. There were no differences in distribution of TAFI polymorphisms between groups.

CONCLUSIONS Patients with RIF have reduced plasma fibrinolytic potential, as shown by a prolonged CLT, and this may be explained, at least in part, by increased TAFI antigen levels.

© The Author 2011. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com This ArticleHum. Reprod. (2011) 26 (3): 510-516. doi: 10.1093/humrep/deq369 First published online: January 7, 2011

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Constitutional change of Italian legislation on assisted reproduction technology improves pregnancy rate especially in older patients

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Paola Scaruffi1, Maria Rita Primavera1, Luiza Helena Abbamonte1, Shanti Levi1, Caterina De Leo2, Annamaria Nicoletti1 and Paola Anserini1,*

1Center of Physiopathology of Human Reproduction, Department of Obstetrics and Gynecology, ‘San Martino’ Hospital, L.go R. Benzi, 10, 16132 Genova, Italy

2Department of Obstetrics and Gynecology, University of Genova, Genova, Italy *Correspondence address. Tel: +39-010-5555843; Fax: +39-010-5556909; E-mail: paola.anserini{at}hsanmartino.itSir,

In February 2004, the Italian Parliament approved a law (namely 40/2004) regulating assisted reproduction technology ( Benagiano and Gianaroli, 2004). This law imposed many limitations on Italian reproductive specialists. The most important of these restrictions was the provision that no more than three oocytes could be fertilized at one time during an IVF treatment, since all embryos obtained had to be transferred simultaneously. On May 2009, the Italian Constitutional Court outlawed some restrictions set out in the 40/2004 law ( Benagiano and Gianaroli, 2010). The most important point of the ruling is that embryo protection is limited by the imperative to ensure a concrete possibility to achieve a successful pregnancy. The Court also strongly reaffirmed the supremacy of the physician's judgment in carrying out a full evaluation and a personalized treatment plan for each woman and couple. Therefore, Italian reproductive specialists can now define an individualized optimal number of embryos to give the best chance of achieving a pregnancy while limiting the number of cryopreserved embryos.

The recently published article by Levi Setti et al. (2010) reported a retrospective analysis of 3274 IVF cycles, comparing fresh cycles before and after the 40/2004 law was modified. No significant difference was found between the two groups in terms of patients’ age, basal FSH levels, …

This ArticleHum. Reprod. (2011) 26 (4): 959-961. doi: 10.1093/humrep/der014 First published online: February 11, 2011

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To continue or discontinue storage of cryopreserved embryos? Patients' decisions in view of their child wish

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V. Provoost1,*, G. Pennings1, P. De Sutter2, J. Gerris2, A. Van de Velde2 and M. Dhont2

1Bioethics Institute Ghent, Ghent University, Blandijnberg 2, B-9000 Ghent, Belgium

2Department of Reproductive Medicine, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium *Correspondence address. E-mail: veerle.provoost{at}ugent.beReceived August 19, 2010. Revision received November 23, 2010. Accepted December 3, 2010. OBJECTIVE Cryopreservation of supernumerary embryos resulting from IVF treatment offers extra chances to conceive. The objective of this study is to describe patients’ decisions to continue or discontinue storage of their embryos after a minimum storage period of 2 years.

METHODS Female patients who had embryos stored at the Infertility Centre of the Ghent University Hospital (Belgium) were sent a mail questionnaire to be completed anonymously.

RESULTS The questionnaire had a response rate of 79% (326/412). After an embryo storage period of at least 2 years, 40% of the couples who were still together wished to continue storage of their embryos. Half of these had no concrete plans for a transfer and wanted to postpone the decision or keep all options open. For those who decided to discontinue storage (60%), the main reason was the completion of their families. Despite the fact that the patients’ child wish was the main factor in their storage decision, two groups of patients with distinct profiles made decisions that were inconsistent with their child wish: those who wanted to continue storage while not wanting a(nother) child (7% of those with no child wish), and those who wanted a(nother) child but decided to discontinue storage (25% of those with a child wish). Overall, these patients more often expressed emotional difficulties regarding this decision.

CONCLUSIONS This study demonstrates the importance of gaining more insight into patients’ embryo storage decisions (along with their embryo disposition decisions) and into the emotional factors playing a role in patients’ decision-making.

© The Author 2011. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com This ArticleHum. Reprod. (2011) 26 (4): 861-872. doi: 10.1093/humrep/deq392 First published online: January 18, 2011

Disclaimer: Please note that abstracts for content published before 1996 were created through digital scanning and may therefore not exactly replicate the text of the original print issues. All efforts have been made to ensure accuracy, but the Publisher will not be held responsible for any remaining inaccuracies. If you require any further clarification, please contact our Customer Services Department.

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