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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. [ABSTRACT FROM AUTHOR]

This study examines the formation of group cohesion and social support in exercise classes among former sedentary adults, participating in a Danish community-based intervention. Furthermore, the aim is to analyze the impact of this process on exercise activity among the participants. A multimethod approach was used, analyzing both survey data and 18 personal interviews collected among 87 participants who completed the intervention project. Analysis was performed according to the grounded theory method. The formation of group cohesion was conditioned by the social composition of the group, the teaching ability by the instructors, and the activity by itself. The cohesive group was characterized by an attitude of mutual support toward exercise activities. This mutual support facilitated development of self-efficacy beliefs among the participants improving their mastery expectation regarding exercise. Manipulating group dynamics may be a promising intervention tool in the promotion of leisure-time physical activity.

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. [ABSTRACT FROM AUTHOR]

Study Question: How are educational level, labor market attachment and income associated with receiving a first ART treatment in either the public or private healthcare sector among women in Denmark?Summary Answer: Higher educational level and income as well as labor market attachment were associated with higher probability of initiating ART treatment at public and private fertility clinics among women in Denmark.What Is Known Already: Infertility is common in populations worldwide, and the approach to this issue differs between societies and healthcare systems. In the public Danish healthcare system, ART treatment is free of charge, and the direct cost for patients is therefore low. In the private healthcare sector in Denmark, ART treatment is self-financed. There is limited knowledge about the association between socioeconomic factors and seeking ART treatment, although previous studies have indicated that higher socioeconomic status is associated with seeking ART treatment.Study Design, Size, Duration: Women undergoing ART treatment during 1994-2016 registered in the Danish IVF register were individually linked with data from sociodemographic population registers using the Danish Personal Identification number. The study population consisted of 69 018 women treated with ART and 670 713 age-matched comparison women from the background population with no previous history of ART treatment.Participants/materials, Setting, Methods: The women included in the analyses were aged 18-45 years. The associations between attained educational level, labor market attachment and income and receiving a first ART treatment attempt were investigated for women either initiating treatment in the public sector or in the private sector, respectively. Information on age and origin was included as potential confounders, and odds ratios (ORs) were estimated in logistic regression models. In addition, analyses were stratified by age group to investigate potential differences across the age span.Main Results and the Role Of Chance: Adjusted results showed increased odds of receiving a first ART treatment in either the public or private sector among women with a higher educational level. Furthermore, women in employment were more likely to receive a first ART treatment in the public or private sector compared to women outside the workforce. The odds of receiving a first ART treatment increased with increasing income level. Surprisingly, income level had a greater impact on the odds of receiving a first ART treatment in the public sector than in the private sector. Women in the highest income group had 10 times higher odds of receiving a first ART treatment in the public sector (OR: 10.53 95% CI: 10.13, 10.95) compared to women in the lowest income group. Sub-analyses in different age groups showed significant associations between ART treatment and income level and labor market attachment in all age groups.Limitations, Reasons For Caution: Our study does not include non-ART treatments, as the national IVF register did not register these types of fertility treatments before 2007.Wider Implications Of the Findings: In Denmark, there is equal access to medically assisted reproduction treatment in the publicly funded healthcare system, and since there is no social inequality in the prevalence of infertility, social inequality in the use of ART treatment would not be expected as such. However, our results show that social inequality is found for a first ART treatment attempt across publicly and privately funded ART treatment across the socioeconomic indicators, educational level, labor market attachment and income.Study Funding/competing Interest(s): The funding for the establishment of the Danish National ART-Couple II Cohort (DANAC II Cohort) was obtained from the Rosa Ebba Hansen Foundation. The authors have no conflict of interest to declare.Trial Registration Number: N/A. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Most previous studies about fertility knowledge and attitudes among men have been based on quantitative methods using questionnaires with fixed-choice response options. The aims of this qualitative study were to explore childless young men's reflections on fertility and infertility through semi-structured interviews. Danish (n = 17) and Swedish (n = 12) young childless men aged between 20 and 30 years in their last year of education were interviewed. Data were analysed using qualitative content analysis. Few informants had considered their own fertility, and most were positive towards fertility treatment. The young men had inadequate knowledge about factors that can potentially impair male and female fertility. On average, the young men each mentioned three different factors they believed influence male and female fertility: (i) health behaviour; (ii) factors beyond personal control; and (iii) age. None mentioned sexual transmitted infections (STIs) but most appeared aware of the effect of increasing age on fertility. The results of this study highlight the need for educational strategies to improve young men's knowledge about fertility and the factors that influence it, particularly about the potential adverse effect of STIs on fertility. [ABSTRACT FROM AUTHOR]

In high-income countries, parental age at first birth has increased and this postponement increases the risk of involuntary childlessness or having fewer children than desired. This interview study was conducted in Denmark and Sweden among childless men (n = 29) in their last year of an education. The aim was to explore the role of individual and societal factors on fertility decision-making and men's reflections on barriers and enablers for earlier family formation. Data were analysed with thematic content analysis. Almost all participants wanted children in the future. Overall, there was a desire to follow the 'right chronology': get educated, having a stable relationship, employment and a good financial status before having children. While most men felt mature enough to have children, they were still not ready. Influences from within the inner social circle, societal expectations, the need for security and stability and being ready to give up freedom and individuality were factors that affected participants' preferred timing of parenthood. Most men did not have suggestions for how earlier family formation could be supported. Results suggest a gap between the ideal biological and ideal social age of family formation that may lead to unfulfilled parenthood aspirations. [ABSTRACT FROM AUTHOR]

Study Question: What is the risk of death among men with oligospermia, unspecified male factor and azoospermia in the years following fertility treatment?Summary Answer: No significantly elevated risk was observed among men with oligospermia and unspecified male factor, while an increased risk was found among men with azoospermia.What Is Known Already: Previous studies have shown associations between male factor infertility and risk of death, but these studies have relied on internal reference groups and the risk of death according to type of male infertility is not well characterized.Study Design, Size, Duration: In this prospective record-linkage cohort study, we identified men who had undergone medically assisted reproduction (MAR) between 1994 and 2015. Data was linked to the Danish causes of death register and sociodemographic registers through personal identification numbers assigned to all Danish citizens at birth.Participants/materials, Setting, Methods: Men that had undergone MAR in Denmark (MAR Cohort; n = 64 563) were identified from the Danish IVF register, which includes data on whether infertility was due to male factor. For each man in the MAR cohort, five age-matched men who became fathers without fertility treatment were selected from the general population (non-MAR fathers; n = 322 108). Men that could not adequately be tracked in the Danish CPR register (n = 1259) and those that were censored prior to study entry (n = 993) were excluded, leaving a final population of 384 419 men. Risk of death was calculated by Cox regression analysis with age as an underlying timeline and adjustments for educational attainment, civil status and year of study entry. The risk of death was compared among men with and without male factor infertility identified from the IVF register (internal comparisons) as well as to the non-MAR fathers (external comparison).Main Results and the Role Of Chance: The risk of death between the MAR cohort (all men, regardless of infertility) and the non-MAR fathers was comparable [hazard ratio (HR), 1.07; 95% CI, 0.98-1.15]. When the MAR cohort was limited to infertile men, these men were at increased risk of death [HR, 1.27; 95% CI, 1.12-1.44]. However, when stratified by type of male factor infertility, men with azoospermia had the highest risk of death, which persisted when in both the internal [HR, 2.30; 95% CI, 1.54-3.41] and external comparison [HR, 3.32; 95% CI, 2.02-5.40]. No significantly elevated risk of death was observed among men with oligospermia [HR, 1.14; 95% CI, 0.87-1.50] and unspecified male factor [HR, 1.10; 95% CI, 0.75-1.61] compared with the non-MAR fathers. The same trends were observed for the internal comparison.Limitations, Reasons For Caution: Duration of the follow-up was limited and there is limited generalizability to infertile men who do not seek fertility treatment.Wider Implications Of the Findings: Using national health registers, we found an increased risk of death among azoospermic men while no increased risk was found among men with other types of infertility. For the azoospermic men, further insight into causal pathways is needed to identify options for monitoring and prevention.Study Funding/competing Interest(s): This study is part of the ReproUnion collaborative study, co-financed by the European Union, Interreg V ÖKS. C.G.'s research stay at Stanford was funded by grants from the University of Copenhagen, Kong Christian den Tiendes Fond, Torben og Alice Frimodt Fond and Julie Von Müllen Fond. M.E. is an advisor for Sandstone and Dadi. All other authors declare no conflict of interests.Trial Registration Number: Not relevant. [ABSTRACT FROM AUTHOR]

Study Question: Is the first-time redeemed prescription of antidepressants predicted by the level of infertility-related stress in women seeking ART treatment?Summary Answer: Infertility-related stress in the personal and marital domains and general physical stress reactions were significant predictors of a first redeemed prescription of antidepressants after ART treatment in this 10-year follow-up cohort study.What Is Known Already: The literature has found inconsistent findings regarding the association between infertility-related stress and later psychological adjustment in fertility patients. The association between infertility-related stress and later prescription of antidepressants had never been explored in long-term cohort studies.Study Design, Size, Duration: All women (n = 1169) who participated in the Copenhagen Cohort Multi-centre Psychosocial Infertility (COMPI) cohort study in the year 2000 (questionnaire data) were linked with the register-based Danish National ART-Couple (DANAC) I cohort, which includes women and their partners having received ART treatment from 1 January 1994 to 30 September 2009. The study population were among other national health and sociodemographic registers further linked with the Danish National Prescription Registry.Participants/materials, Setting, Methods: Women initiating ART treatment were followed until they had redeemed the first prescription of antidepressants or until 31 December 2009. Logistic regression analyses were conducted to test the association between general physical stress reactions and infertility-related stress in the personal, marital and social domains, respectively, and a future redeemed prescription of antidepressants. Age, education level, marital status, number of fertility treatments prior to study inclusion and female infertility diagnosis were included as covariates in the adjusted analyses. Further, the analysis was stratified according to childbirth or no childbirth during follow-up.Main Results and the Role Of Chance: The final sample consisted of 1009 women with a mean age of 31.8 years. At study inclusion, women had tried to conceive for an average of 3.45 years. At 10-year follow-up, a total of 13.7% of women had a first redeemed prescription of antidepressant medication. The adjusted odds ratio (OR) showed that high general physical stress predicted the later prescription of antidepressants (adjusted (adj) OR = 2.85, 95% confidence interval (CI) 1.96-4.16). Regarding infertility-related stress domains, high personal stress (adj OR = 2.14, 95% CI 1.46-3.13) and high marital stress (adj OR = 1.80, 95% CI 1.23-2.64) were significantly associated with the later prescription of antidepressants. Social stress was not significantly associated with the future redeemed prescription of antidepressants (adj OR = 1.10, 95% CI 0.76-1.61). Among women not having achieved childbirth during follow-up, the risk of a first-time prescription of antidepressants associated with infertility-specific stress was higher compared to the risk among women having childbirth during follow-up.Limitations, Reasons For Caution: This study did not account for potential mediating factors, such as negative life events, which could be associated with the prescription of antidepressants. Second, we are not able to know if these women had sought psychological support during follow-up. Additionally, antidepressants might be prescribed for other health conditions than depressive disorders.Wider Implications Of the Findings: Our results suggest that women presenting high infertility-related stress in the personal and marital domains were at higher risk of redeemed first-time prescription of antidepressants after ART, independently of having delivered a child or not after initiation of ART treatment. Women would benefit from an initial screening specifically for high infertility-related stress. The COMPI Fertility Problem Stress Scales can be used by clinical staff in order to identify women in need of psychological support before starting ART treatments.Study Funding/competing Interest(s): This study was supported by the Portuguese Foundation for Science and Technology (FCT) under an individual doctoral grant attributed to the first author (SFRH/BD/103234/2014). The establishment of the DANAC I cohort was funded by Rosa Ebba Hansen's Fund. The COMPI Infertility Cohort project was supported by The Danish Health Insurance Fund (J.nr. 11/097-97), the Else and Mogens Wedell-Wedellsborgs Fund, the manager E. Danielsens and Wife's Fund, the merchant L.F. Foghts Fund, the Jacob Madsen and Wife Olga Madsens Fund. The authors have no conflicts of interest.Trial Registration Number: NA. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

In previous studies, investigators have reported reduced mortality among women undergoing assisted reproductive technology (ART) treatment, possibly related to selection of healthy women into ART treatment. Our aim in this study was to explore the impact of relevant selection factors on the association between ART treatment and mortality and to explore effect modification by parity. Women treated with ART in fertility clinics in Denmark during 1994–2009 (n = 42,897) were age-matched with untreated women from the background population (n = 204,514) and followed until December 31, 2010. With adjustment for relevant confounders, the risk of death was lower among ART-treated women during the first 2 years after ART treatment (hazard ratio (HR) = 0.68, 95% confidence interval (CI): 0.63, 0.74), but there was no apparent difference after 10 years (HR = 0.92, 95% CI: 0.79, 1.07). Having children prior to ART treatment was associated with markedly reduced mortality (HR = 0.45, 95% CI: 0.38, 0.53), possibly due to better health among fertile women. While the frequencies of previous medical and psychiatric diagnoses among ART-treated and untreated women were similar, differences in disease severity could explain the reduced mortality among ART-treated women, as poor prognosis would make initiation of ART treatment unlikely. The survival advantage among ART-treated women is likely a selection phenomenon rather than a biological phenomenon. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Study Question: Are couples initiating ART treatment at higher risk for future union dissolution compared to other couples?Summary Answer: There is no effect of ART treatments in future marital dissolution over a period of 16 years when adjusting for all confounders.What Is Known Already: Findings regarding marital stability and infertility treatments have been sparse and controversial. While there is data showing higher divorce rates among women who go through infertility treatments, there is also some evidence of this experience bringing couples closer by forcing them to communicate more and to deal with the surrounding stigma. Using a population-based study and couple-level data, we investigated the extent to which ART treatment increases the risk for divorce/marital dissolution during up to 16 years of follow-up.Study Design Size, Duration: Register-based national cohort study including all women registered with ART treatment in Denmark between 1 January 1994 and 30 September 2009 (n = 42 845). Marital/cohabiting status was confirmed by matching these women to partners who they were married to or shared an address with. To account for having a significant relationship at baseline (2 years), marital/cohabiting status was confirmed by accessing this variable before the establishment of the cohort back to 1 January 1992.Participants/materials, Setting, Methods: A comparison group from the background population including five controls per case and matched to female age at baseline was prospectively sampled. Participants could change status during follow-up if they entered ART. The final sample had 148 972 couples, followed until marital dissolution, death of self/spouse, migration or until 31 December 2010. We used Cox regression models adjusting for female and male age, education, marriage, common child at baseline and live-born child during follow-up.Main Results and the Role Of Chance: At baseline, the majority of couples were married (69%). More non-ART couples opted for marriage (70% versus 64%; P < 0.0001) and already had common children at study entry (43% versus 9%; P < 0.0001). During the 16 years of follow-up the majority of couples had children with their baseline partners (56% non-ART versus 65% ART), and 22% ended up separated or divorced (20% ART versus 22% non-ART). Findings revealed a lower risk of break-up among ART couples (crude HR 0.84, 95% CI 0.82-0.86), even after adjusting for both partners' age, education, partnership status and having a common child at baseline (adj HR 0.83, 95% CI 0.80-0.86). However, when subsequent common children (time-dependent) was added to the model, no difference in the risk of dissolution was found (adj HR 1.00, 95% CI 0.99-1.01). A significant interaction between ART status and common children showed that the risk of break-up was attributed to childlessness regardless of having gone through ART treatment.Limitations Reason For Caution: This study did not control for involuntary childlessness, non-ART fertility care (ovulation induction, IUI) and biological parenthood. Additionally, there are important predictors of divorce that were not considered. We were unable to adjust for religion, existence of previous marital relationships, income, employment, health status of parents and child(ren), and quality of relationship.Wider Implication Of Findings: The finding that going through ART does not increase the risk of break up per se is reassuring for couples who underwent ART and have children or are contemplating to start ART.Study Funding/competing Interest(s): This work was supported by FCT (Portuguese Foundation for Science and Technology), grant ref. SFRH/BPD/85789/2012. The authors have no conflicts of interest.Trial Registration Number: N/A. [ABSTRACT FROM AUTHOR]

Study Question: Is male factor infertility associated with an increased risk of developing diabetes?Summary Answer: The study provides evidence that male factor infertility may predict later occurrence of diabetes mellitus with the risk being related to the severity of the underlying fertility problem.What Is Known Already: Previous cross-sectional studies have shown an increased prevalence of comorbidities among infertile men when compared to controls.Study Design, Size, Duration: In this prospective cohort study, 39 516 men who had since 1994 undergone fertility treatment with their female partner were identified from the Danish national IVF register, which includes data on assumed cause of couple infertility (male/female factor, mixed and unexplained infertility) and type of fertility treatment. With a median follow-up time of 5.6 years, each man was followed for diabetes occurrence from enrollment until 31 December 2012 using the National Diabetes Register (NDR). Men with a history of diabetes prior to their fertility diagnosis were excluded. Hazard ratios (HR) were estimated by Cox proportional hazard models with age as the underlying time scale. In addition to analyzing the data for the entire IVF registration period (1994-2012), separate analyses were performed for men identified from the first (1994-2005) and second (2006-2012) IVF registration period owing to heterogeneity in the reporting of male factor infertility in these two time periods, because the reason for male factor infertility was not available from the first register.Participants/materials, Setting, Methods: Male factor infertility was identified from the variable 'yes' or 'no' from the first IVF register and through a diagnosis code (e.g. oligospermia, azoospermia) from the second IVF register. The reference group was men with male factor infertility (='no') and those with normal semen quality or sterilized men. Of the included men, 18 499 (46.8%) had male factor infertility and 21 017 (53.2%) made up the reference group.Main Results and the Role Of Chance: A total of 651 (1.6%) diabetes cases were identified during the follow-up period. The adjusted HR's for diabetes risk among men with male factor infertility when compared to the reference group were HR = 1.08 (95% CI: 0.89, 1.31) and HR = 1.45 (95% CI: 1.06, 1.97) for the first and second IVF registration period, respectively. When assessing the effects of individual causes of male factor infertility, the adjusted HR's for men with oligospermia, azoospermia and aspermia were HR = 1.44 (95% CI: 1.01, 2.06), HR = 2.10 (95% 1.25, 3.56) and HR = 3.20 (95% CI 1.00, 10.31), respectively.Limitations, Reasons For Caution: We found no increased risk among men identified from the first IVF register, which may be related to exposure misclassification as the reason for male factor infertility was not available from this time period. The NDR does not distinguish between type 1 and type 2 diabetes.Wider Implications Of the Findings: These findings support previous studies that a man's reproductive and somatic health are closely intertwined and highlight the importance for further monitoring of these men. Further, implementation of diabetes screening may be especially relevant among aspermic and azoospermic men.Study Funding/competing Interests: This article is part of the ReproUnion collaborative study, co-financed by the European Union, Intereg V Öresund-Kattegat-Skagerrak. None of the authors declare any conflict of interest.Trial Registration Number: None. [ABSTRACT FROM AUTHOR]

Study Question: Are the Copenhagen Multi-Centre Psychosocial Infertility research program Fertility Problem Stress Scales (COMPI-FPSS) a reliable and valid measure across gender and culture?Summary Answer: The COMPI-FPSS is a valid and reliable measure, presenting excellent or good fit in the majority of the analyzed countries, and demonstrating full invariance across genders and partial invariance across cultures.What Is Known Already: Cross-cultural and gender validation is needed to consider a measure as standard care within fertility. The present study is the first attempting to establish comparability of fertility-related stress across genders and countries.Study Design Size, Duration: Cross-sectional study. First, we tested the structure of the COMPI-FPSS. Then, reliability and validity (convergent and discriminant) were examined for the final model. Finally, measurement invariance both across genders and cultures was tested.Participants/materials, Setting, Methods: Our final sample had 3923 fertility patients (1691 men and 2232 women) recruited in clinical settings from seven different countries: Denmark, China, Croatia, Germany, Greece, Hungary and Sweden. Participants had a mean age of 34 years and the majority (84%) were childless.Main Results and the Role Of Chance: Findings confirmed the original three-factor structure of the COMPI-FPSS, although suggesting a shortened measurement model using less items that fitted the data better than the full version model. While data from the Chinese and Croatian subsamples did not fit, all other counties presented good fit (χ2/df ≤ 5.4; comparative fit index ≥ 0.94; root-mean-square error of approximation ≤ 0.07; modified expected cross-validation index ≤ 0.77). In general, reliability, convergent validity, and discriminant validity were observed in all subscales from each country (composite reliability ≥ 0.63; average variance extracted ≥ 0.38; squared correlation ≥ 0.13). Full invariance was established across genders, and partial invariance was demonstrated across countries.Limitations Reasons For Caution: Generalizability regarding the validation of the COMPI-FPSS cannot be made regarding infertile individuals not seeking treatment, or non-European patients. This study did not investigate predictive validity, and hence the capability of this instrument in detecting changes in fertility-specific adjustment over time and predicting the psychological impact needs to be established in future research.Wider Implications Of the Findings: Besides extending knowledge on the psychometric properties of one of the most used fertility stress questionnaire, this study demonstrates both research and clinical usefulness of the COMPI-FPSS.Study Funding/competing Interests: This study was supported by European Union Funds (FEDER/COMPETE-Operational Competitiveness Program, and by national funds (FCT-Portuguese Foundation for Science and Technology) under the projects PTDC/MHC-PSC/4195/2012 and SFRH/BPD/85789/2012). There are no conflicts of interest to declare.Trial Registration Number: N/A. [ABSTRACT FROM AUTHOR]

Background: Postponing parenthood has steadily increased during the past decades in Western countries. This trend has affected the size of families in the direction of fewer children born per couple. In addition, higher maternal age is associated with an increased risk of pregnancy-related complications such as prematurity and foetal death, while higher paternal age increases the risk of miscarriage and affects time-to-pregnancy. Hence, understanding the circumstances and reflections that influence the decision is greatly needed and little is known about potential gender difference influencing the choice. The aim was to investigate attitudes towards parenthood, intentions for childbirth and knowledge about fertility issues among men and women. Methods: We conducted a cross-sectional study based on a validated 49-item questionnaire among students, who attended selected mandatory lectures at a Danish university college in February to April 2016. The participation rate was 99%, and 517 completed the questionnaire. Results: Though the majority of all participants wished to have children in the future (>86%), there was significant difference between the genders (p = 0.002). Women rated having children to be more important than men did (p < 0.001), while men rated higher the likelihood of abstaining from having children if faced with infertility (p = 0.003). Knowledge about fertility issues was similar between genders including poor knowledge about the age-related decline in female fertility. While women found it more important to have children before being 'too old' (p = 0.04), still more than 40% of all respondents intended to have their last child after the age of 35 years. For both genders the most important prerequisite for parenthood was having a partner to share responsibility with. Perceived or experienced life changes related to parenthood were generally positive such as personal development. Conclusion: The majority of respondents wished to have children, but many desired to have these after the biological decline in female fertility. The moderate knowledge level among both genders uncovered in this study is of concern. Future research should address the potential link between fertility knowledge and planning of parenthood. We may benefit from intervention studies examining the effect of routine preconception care. [ABSTRACT FROM AUTHOR]

Introduction: Until recently, limited options for preserving fertility in order to delay childbearing were available. Although egg freezing and successful thawing is now possible, it remains unclear to what extent women are aware of the availability of this technique, their attitudes towards its use, or the circumstances under which this technique may be considered.Material and Methods: An online cross-sectional survey was designed to investigate knowledge and attitudes of women in Denmark and the UK on egg freezing and their potential intentions regarding the procedure.Results: Data was collected from September 2012 to September 2013 and the responses of 973 women were analyzed. In total, 83% of women reported having heard of egg freezing, and nearly all considered it acceptable for medical indications, whilst 89% considered it acceptable for social reasons. Overall, 19% expressed active interest in the procedure, and 27% expressed possible interest. Key factors found to positively influence attitudes to accepting the procedure were reassurance that it would not affect future fertility and greater than 50% chance of achieving a live birth. Characteristics significantly associated with intention to freeze eggs were being single, age under 35 years, childlessness, and a history of infertility. In this group, risk and cost were less important considerations.Conclusions: This study indicates that there is widespread awareness and support of the availability of eggs freezing for reproductive planning. Reassurance regarding its efficacy appears more important than its potential adverse effects on their health or that of future children, or the costs of the procedure. [ABSTRACT FROM AUTHOR]

Introduction:Fertility counselling for young women newly diagnosed with cancer is an important field of preconceptional counselling. This qualitative, small-scale study explored how young women newly diagnosed with cancer experienced specialized fertility preservation counselling and treatment in the public Danish health care system. Methods:Semi-structured, in-depth interviews were conducted with five women below 40 years recently diagnosed with cancer. All women received fertility counselling by a fertility specialist at the Fertility Clinic, University Hospital of Copenhagen, Denmark before initiation of cancer treatment. Participants were interviewed at a place chosen by them, and interviews were recorded and transcribed verbatim. Data were analysed using systematic text condensation developed by Malterud and inspired by Giorgi’s phenomenological analysis. Results:None of the participants were aware that chemotherapy could destroy their eggs. The participants described how specialized fertility counselling and fertility preservation contributed to a belief in life after cancer, which gave them hope that they would survive their cancer disease. Further, the women described how the possibility of fertility preservation removed a huge concern and enabled them to concentrate on their cancer treatment and on getting better. Conclusion:Overall, the specialized fertility counselling and treatment to preserve fertility was highly valued. The women felt it gave them a choice about their future fertility. The fertility expert presented the various fertility-preserving scenarios, and the women were content that they had an actual choice. [ABSTRACT FROM PUBLISHER]

Background:Across several European countries family formation is increasingly postponed. The aims of the study were to investigate the desire for family building and fertility awareness in the UK and Denmark. Methods:A population-based internet survey was used among women (n = 1,000) and men (n = 237) from the UK (40%) and Denmark (60%). Data covered socio-demographics, family formation, and awareness of female age-related fertility. Data analysis used descriptive statistics and logistic regression analysis for studying associations between low fertility awareness and desired family formation. Results:The majority of all participants desired two or three children. Two-thirds of the childless participants desired a first child at 30+ years, and one-fifth of the women and one-third of the men desired a last child at age 40. Overall, 83% of women and 73% of men were aware that female fertility starts to decline around 25–30 years. Men had significantly lower fertility awareness. Women who underestimated the impact of age on female fertility were significantly more likely to have a desire or attempted their first child at a higher age. Conclusion:Even though the majority were aware of the age-related decrease in female fertility, most desired having children at an age when female fertility has declined. Women who were not sufficiently aware of the impact of advanced age were significantly more likely to have their first child at a higher age. There is a need for developing educational programs for women and men in order to increase the population’s knowledge of fertility and risk factors for infertility. [ABSTRACT FROM PUBLISHER]

Introduction: This national retrospective cohort study investigates the prevalence of women with severe eating disorders in assisted reproductive technology (ART) treatment compared with an age-matched background population without ART treatment. It assesses the frequency distribution of the first and last eating disorder diagnosis before, during, and after ART treatment, and evaluates differences in obstetric outcomes between women with and without a severe eating disorder. Material and Methods: Hospital-diagnosed eating disorders among 42,915 women in the Danish National ART cohort (DANAC), registered during 1994-2009 in the mandatory Psychiatric Central Research Register, were compared with a non-eating disorder ART cohort of 42,644 women and an age-matched background population of 215,290 women without a history of ART treatment for the main outcome measures prevalence of eating disorders, frequency distribution of diagnoses before/during/after ART treatment, as well as ART treatment and obstetric outcomes. Results: In the ART cohort, 271 women (0.63%) had an eating disorder diagnosis compared with 0.73% in the background population (p = 0.025). The prevalence of ovulatory disorder was significantly higher in women with a severe eating disorder compared with the ART cohort without eating disorders. Obstetric outcomes were similar in ART-treated women with and without an eating disorder. Conclusion: Women with severe eating disorders were identified in the ART cohort, although significantly less often than in the age-matched background population. Women with severe eating disorders suffered more often from anovulatory infertility than the ART comparison cohort without this disease. Obstetric outcomes appeared reassuring in the ART cohort with eating disorders. [ABSTRACT FROM AUTHOR]

Infertility and fertility treatment have the potential to impact and disrupt a couple's overall life. In order to study the associations between the impact of childlessness on one's life, and men and women's attitudes towards fertility treatment continuation and/or adoption, we analysed data from a one-year follow-up questionnaire in a prospective, longitudinal cohort study of consecutive couples initiating fertility treatment in Denmark. The study comprised 302 couples with no children at baseline and no joint children at one-year follow-up. In total, 71.9% of women and 72.5% of men reported that they wished to continue fertility treatment, while 20.2% of women and 19.2% of men reported that they wished to pursue adoption. The attitudes of nearly 8 in 10 couples were congruent towards further fertility treatments, while nearly 7 in 10 couples were congruent in their attitudes to pursuing adoption. Significantly more men who reported a lower impact of childlessness on their daily life wished to continue fertility treatment, compared with those reporting that childlessness had a greater impact on their life. Among women, significantly more were undecided about whether or not to pursue adoption when reporting a greater impact of childlessness on social life, compared with those reporting a lower impact of their childlessness. [ABSTRACT FROM AUTHOR]

STUDY QUESTION Are severe depressive symptoms in women and men associated with individual and dyadic infertility-related stress in couples undergoing infertility treatment? SUMMARY ANSWER Severe depressive symptoms were significantly associated with increased infertility-related distress at both the individual and partner level. WHAT IS KNOWN ALREADY? An infertility diagnosis, the stress of medical treatments and a prior history of depression are risk factors for future depression in those undergoing fertility treatments. Studies examining the impact of severe depressive symptoms on infertility-related distress in couples are lacking. STUDY DESIGN, SIZE, DURATION This cross-sectional study included 1406 couples who were consecutively referred patients undergoing fertility treatments in Denmark in the year 2000. A total of 1049 men and 1131 women were included in the study. PARTICIPANTS/MATERIALS, SETTING, METHODS Participants were consecutively referred patients undergoing a cycle of medically assisted reproduction treatment at five Danish public and private clinics specializing in treating fertility patients. Severe depressive symptoms were measured by the Mental Health Inventory 5 from the Short Form Health Survey 36. Infertility distress was measured by the COMPI Fertility Problem Stress Scales. Multilevel modelling using the actor–partner interdependence model was used to study the couple as the unit of analysis. MAIN RESULTS AND THE ROLE OF CHANCE Severe depressive symptoms were reported in 11.6% of women and 4.3% of men, and were significantly associated with increased infertility-related distress at the individual and partner level. There was no significant interaction for gender indicating that men and women did not differ in how severe depressive symptoms were associated with infertility distress. LIMITATIONS, REASON FOR CAUTION Because of the cross-sectional study design, the study findings only show an association between severe depressive symptoms to individual and partner distress at a single point in time; however, nothing is known about causality. WIDER IMPLICATIONS OF THE FINDINGS This study adds to the growing body of literature using the couple as the unit of analysis to study the relationship between depression and infertility distress. Recommendations for medical and mental health professionals that underscore the potential risk factors for depressed men and women who are pursuing infertility treatments are provided. Additional studies using a longitudinal study design to track the impact of depression on distress over the course of the infertility treatment cycle would be valuable for increasing our understanding of the complex relationship that exists between these psychosocial factors. STUDY FUNDING/COMPETING INTERESTS Authors Brennan Peterson and Matthew Pirritano have no financial disclosures for this study. Camilla Sandal Sejbaek and Lone Schmidt have received research grants from the Danish Health Insurance Foundation (J. nr. 2008B105) and Merck Sharp & Dohme. The funders had no influence on the data collection, analyses or conclusions of the study. [ABSTRACT FROM PUBLISHER]

Individuals perceiving high social support tend to perceive better adjustment to infertility. However, it remains unclear whether this benefit is affected by the actual disclosure of the infertility condition. The present study aimed to examine the role of disclosure of fertility status in moderating the relationship between perceived social support and fertility-related stress. The study population (N = 698) was drawn from a longitudinal cohort design of Danish men and women beginning fertility treatment with a 12-month follow-up. Participants were 698 subjects (364 women and 334 men) who completed self-administered questionnaires measuring perceived social support at T1, and fertility status disclosure and fertility stress at T2. Results indicated that when infertility is not disclosed to at least a close relationship, the beneficial effects of social support on both social and personal stress cease to exist. Also, when participants perceived high social support, higher levels of social and personal stress were associated with keeping infertility a secret within close relationships, but when low social support was perceived, high social and personal stress levels were associated with disclosing infertility to all close relationships. Findings from this study provide evidence that the prospective relationship between social support and fertility-related stress is moderated by the decision of disclosing infertility. Infertility health professionals can help couples in deciding to which contexts they should disclose their infertility by assessing social support. [ABSTRACT FROM PUBLISHER]

Aims: Infertility is highly prevalent and 16—26% of women trying to achieve a pregnancy experience infertility in one or more periods. Several exposures in the work environment have been hypothesized to affect female reproduction. This study aimed to estimate relative rates (RR) of female fertility treatment in the 57 industrial groups in Denmark. Methods: The closed cohort of all 20—39 year old economically active women in Denmark by January 2001 (n = 567,816) were followed-up for hospital contacts due to infertility from 2001 to 2005 as registered in the Danish Occupational Hospital Register. Age-standardized relative rates for being diagnosed as infertile were estimated by industry. Further standardization with respect to socioeconomic status was also performed. Results: In total, 12,575 women were diagnosed with infertility during the follow-up period. Three industries presented with statistically significant elevations in age-standardized RRs: hospitals (RR = 1.27, 95% confidence interval (CI): 1.20—1.35), general and dental practice (RR = 1.17, 95% CI: 1.02—1.35) and other health care (RR = 1.24, 95% CI: 1.09—1.41). Standardization for socioeconomic status rendered two industries that were statistically significantly elevated: manufacture of wood and wood products (RR = 1.20, 95% CI: 1.02—1.42) and hospitals (RR = 1.17, 95% CI: 1.10—1.24). Conclusions: Interpretation of the results is complex, since the relative contributions to the observed inequalities of the work environment and, for example, differences in inclination to start a family or in proneness to seek treatment are difficult to resolve. Withstanding shortcomings and limitations, register data of fertility treatment offers a possibility to suggest industries for further investigation of reproductive health. [ABSTRACT FROM PUBLISHER]

Aims: The aim of this study was to examine the cross‐sectional association between educational attainment and coping strategies with unemployment in a random sample of 37‐ to 56‐year‐old Danish men and women in long‐term unemployment. Methods: Data were based on a survey among 575 men and 1,064 women who had been unemployed at least 70% of the time during a three‐year period (October 1996 to October 1999). The outcome measures were two scales for coping with unemployment, one for problem‐solving coping, and one for avoidant coping. Educational attainment was measured by years of vocational training. Results: A significant association was found between low educational attainment and low use of problem‐solving coping among both men, OR = 1.81 (95% CI 1.19–2.75), and women, OR = 1.57 (1.13–2.18). Adjustment for cohabitation status, self rated health, economic strain, and unemployment status did not change this association substantially. High use of avoidant coping was associated with low educational attainment among men, OR = 1.57 (0.98–2.51). For women, medium educational attainment was significantly associated with low use of avoidant coping, OR = 0.60 (0.42–0.85). This result was not affected by adjustment for the covariates. Conclusions: Coping strategies are considered a potential modifier of the impact of unemployment on health and well‐being. In this study, differences in coping strategies with unemployment were associated with educational attainment. [ABSTRACT FROM AUTHOR]

Background: Twin pregnancies constitute 25% of all in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) pregnancies. There is a lack of knowledge on maternal risks and perinatal outcome of IVF/ICSI twin pregnancies.Methods: National survey by questionnaire (n = 1769). The study population consisted of all IVF/ICSI twin mothers (n = 266) and the two control groups of all IVF/ICSI singleton mothers (n = 764) and non-IVF/ICSI twin mothers (n = 739) who delivered in Denmark in 1997. The response rate was 89% among IVF twin mothers and overall 81%.Results: In terms of maternal risks and perinatal outcome no significant differences were observed between IVF/ICSI twin and non-IVF/ICSI twin pregnancies after stratification for maternal age and parity. Nevertheless, IVF/ICSI twin mothers were more frequently on sick leave (OR 2.5, 95% CI 1.5-4.0) and hospitalized (OR 1.9, 95% CI 1.3-2.8) during pregnancy. Compared with IVF/ICSI singleton pregnancies, IVF/ICSI twin pregnancies were characterized by a higher incidence of preeclampsia (OR 2.4, 95% CI 1.5-4.2) and a higher frequency of sick leave (OR 6.8, 95% CI 4.4-10.5) and hospitalizations during pregnancy (OR 3.5, (95% CI 2.5-4.9); moreover, mean birthweight (p < 0.001) and gestational age (p < 0.001) were lower. No differences were observed in the incidence of pregnancy-induced hypertension and gestational diabetes between IVF/ICSI twin and singleton pregnancies.Conclusion: Although this population study indicates that maternal risks in IVF/ICSI twin pregnancies are comparable with non-IVF/ICSI twin pregnancies, the IVF/ICSI twin mothers were more likely to be on sick leave or hospitalized during pregnancy. Furthermore, maternal risks were higher and obstetric outcome poorer in IVF/ICSI twin vs. IVF/ICSI singleton pregnancies. [ABSTRACT FROM AUTHOR]

• The war in Ukraine and the COVID-19 pandemic have affected international surrogacy • The lack of legal parenthood for intended parents affects the feeling of parenthood • There have been calls for a legal policy on surrogacy in Denmark that addresses issues of legal parenthood How did Danish permanently infertile couples experience surrogacy when going abroad and what impact did the war in Ukraine and the COVID-19 pandemic have on this? A qualitative study was performed between May and September 2022. The in-depth semi-structured interviews were conducted with 14 permanently infertile couples across Denmark who were in different stages of using surrogacy. The interviews were transcribed and analysed using systematic text condensation. All except one couple went abroad, mainly to Ukraine, to have an enforceable transparent contract, professionals to advise them and the possibility of using the eggs of the intended mother. They did not feel that this was a 'choice' but rather the only option they had to have the longed-for child. According to current Danish legislation, the intended mother could not obtain legal motherhood over the child, not even through stepchild adoption, and this increased the feeling of not being a 'worthy mother'. This study expanded on the term 'reproductive exile' by identifying four different forms of exile: the exiled Danish couple, the gestational carrier in exile, exile at home and, finally, the reproductive body in exile. Understanding infertile couples' experiences when crossing borders is important for several reasons. It may, among others, assist politicians and authorities in developing a sound Danish legal policy on surrogacy to address the current issues of legal parenthood and avoid missing reproductive opportunities for permanently infertile couples. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: To assess the relationship between infertility, marital benefit, and coping in a sample of men and women undergoing unsuccessful fertility treatments. Design: Prospective longitudinal cohort design using multilevel modeling. Setting: Danish public and private hospitals (n = 5) specializing in treating fertility patients. Patient(s): Participants were Danish men and women about to start a cycle of medically assisted reproduction treatment who were followed for a 5-year period of unsuccessful treatments. Intervention(s): None. Main Outcome Measure(s): The Copenhagen Multicenter Psychosocial Infertility research program Coping Strategy Scales and Marital Benefit Measure. Result(s): Compared with men, a greater percentage of women reported high levels of marital benefit. For active-avoidance coping, there was a significant partner effect by gender interaction. Meaning-based strategies increased between 1 and 5 years for men and women. The use of meaning-based coping had a significant positive actor effect with marital benefit for both men and women. Conclusion(s): Approximately one-third of participants undergoing unsuccessful fertility treatments reported high marital benefit as a positive consequence of the infertility experience. Partner effects for men and women related to active-avoidance coping may be related to the degree of emotional support that each spouse can offer the other, whereas differences in meaning-based coping indicate a possible timing effect related to gender. [ABSTRACT FROM AUTHOR]

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., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

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., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Gestational surrogacy, in which an infertile couple contracts with a woman to carry a foetus that the intended parents will raise, increases worldwide, and offers a route to parenthood for individuals and couples who otherwise have limited options. However, the situation in Denmark at present is that surrogacy with the help of healthcare professionals is illegal, and international adoption is no longer available. This review gives an overview of the legal situation of surrogacy in Denmark, the impact of the legislation, and medical issues to be aware of as healthcare professionals in the future., (Published under Open Access CC-BY-NC-BD 4.0. https://creativecommons.org/licenses/by-nc-nd/4.0/.)

Study Question: Are there any differences in physical and psychosocial well-being among women undergoing modified natural cycle frozen embryo transfer (mNC-FET) with or without vaginal progesterone as luteal phase support (LPS)?, Summary Answer: Women undergoing mNC-FET with vaginal progesterone supplementation were more likely to experience physical discomfort but there was no difference in psychosocial well-being between the two groups., What Is Known Already: mNC-FET can be carried out with or without vaginal progesterone as LPS, which has several side-effects. It is commonly known that fertility treatment can cause stress and psychosocial strain, however, most studies on this subject are conducted in fresh cycle regimes, which differ from NC-FET and results may not be comparable., Study Design, Size, Duration: This is a sub-study of an ongoing RCT investigating whether progesterone supplementation has a positive effect on live birth rate in mNC-FET. The RCT is conducted at eight fertility clinics in Denmark from 2019 and is planned to end primo 2024. The sub-study is based on two questionnaires on physical and psychosocial well-being added to the RCT in August 2019. On the time of data extraction 286 women had answered both questionnaires., Participants/materials, Setting, Methods: Women who had answered both questionnaires were included in the sub-study. Participants were equally distributed, with 143 in each of the two groups. Participants in both groups received the same questionnaires at two time-points: on cycle day 2-5 (baseline) and after blastocyst transfer. Participants in the progesterone group had administered progesterone for 7 days upon answering the second questionnaire. All items in the questionnaires were validated. Items on psychosocial well-being originate from the Copenhagen Multi-Centre Psychosocial Infertility-Fertility Problem Stress Scale (COMPI-FPSS) and from the Mental Health Inventory-5., Main Results and the Role of Chance: Women receiving progesterone experienced more vaginal itching and/or burning than women in the non-progesterone group (P < 0.001). Women in the progesterone group also experienced more self-reported vaginal yeast infection, this was, however, not significant after adjustment for multiple testing (P/adjusted P = 0.049/0.881). No differences regarding psychosocial well-being were found between the two groups. Within the progesterone group, a shift toward feeling less 'downhearted and blue' was found when comparing response distribution at baseline and after blastocyst transfer (P < 0.001)., Limitations, Reasons for Caution: All items on physical symptoms were self-reported. The item on vaginal yeast infection was therefore not diagnosed by a doctor. Inclusion in the study required a few extra visits to the clinic, participants who felt more burdened by fertility treatment might have been more likely to decline participation. Women who experienced a lot of side-effects to progesterone prior to this FET cycle, might be less likely to participate., Wider Implications of the Findings: Our results are in line with previous known side-effects to progesterone. Physical side-effects of progesterone should be considered before administration., Study Funding/competing Interest(s): The RCT is fully supported by Rigshospitalet's Research Foundation and a grant from Gedeon Richter. Gedeon Richter were not involved in the design of protocol nor in the conduction of the study or analysis of results. A.P., L.P., and N.I.-C.F. report grants from Gedeon Richter, Ferring and Merck with no relations to this study. N.I.-C.F. has received travel support from Ferring, Merck A/S, & Gideon Richter, and is the head of the steering committee for the Danish Fertility Guidelines made by the members of from the Danish Fertility Society. A.P. reports consulting fees from Preglem, Novo Nordisk, Ferring, Gedeon Richter, Cryos, & Merck A/S, honoraria from Gedeon Richter, Ferring, Merck A/S, Theramex, and Organon, has received travel support from Gedeon Richter (payment to institution), participated on an advisory board for Preglem and was loaned an embryoscope from Gedeon Richter to their institution. A.L.S. has stock options for Novo Nordisk B A/S. B.A. have received unrestricted grant from Gedeon Richter Nordic and Merck and honoraria for lectures from Gedeon Richter, Merck, IBSA, and Marckyrl Pharma., Trial Registration Number: The RCT is registered on ClinicalTrials. gov (NCT03795220) and in EudraCT (2018-002207-34)., (© The Author(s) 2023. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Infertility affects 15%-25% of all couples during their reproductive life span. It is a significant societal and public health problem with potential psychological, social, and economic consequences. Furthermore, infertility has been linked to adverse long-term health outcomes. Despite the advanced diagnostic and therapeutic techniques available, approximately 30% of infertile couples do not obtain a live birth after fertility treatment. For these couples, there are no further options to increase their chances of a successful pregnancy and live birth., Objectives: Three overall questions will be studied: (1) What are the risk factors and natural life courses of infertility, early embryonic loss, and adverse pregnancy outcomes? (2) Can we develop new diagnostic and prognostic biomarkers for fecundity and treatment success? And (3) what are the health characteristics of women and men in infertile couples at the time of fertility treatment and during long-term follow-up?, Material and Methods: ReproUnion Biobank and Infertility Cohort (RUBIC) is established as an add-on to the routine fertility management at Copenhagen University Hospital Departments in the Capital Region of Denmark and Reproductive Medicine Centre at Skåne University Hospital in Sweden. The aim is to include a total of 5000 couples equally distributed between Denmark and Sweden. The first patients were enrolled in June 2020. All eligible infertile couples are prospectively asked to participate in the project. Participants complete an extensive questionnaire and undergo a physical examination and collection of biospecimens (blood, urine, hair, saliva, rectal swabs, feces, semen, endometrial biopsies, and vaginal swabs). After the cohort is established, the couples will be linked to the Danish and Swedish national registers to obtain information on parental, perinatal, childhood, and adult life histories, including disease and medication history. This will enable us to understand the causes of infertility and identify novel therapeutic options for this important societal problem., (© 2021 American Society of Andrology and European Academy of Andrology.)

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., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Study Question: Is female infertility predictive of a woman's future risk of early cardiovascular disease (CVD)?, Summary Answer: Female infertility does not seem to be predictive of early CVD during a mean follow-up of 9 years., What Is Known Already: Associations between infertility and comorbidity have been found in several studies, but data on the association between female infertility and risk of CVD are scarce and inconclusive., Study Design, Size, Duration: In this nationwide cohort study, we included 87 221 women registered in the Danish National IVF register, undergoing medically assisted reproduction (MAR) between 1st of January 1994 and 31st of December 2015. The cohort was followed for incident hospitalization due to CVD in the Danish National Patient Register from enrollment to 31 December 2015. Women with a history of CVD prior to enrollment were excluded. Cox proportional hazard models with age as the underlying time scale were used to estimate hazard ratios (HR) with 95% CI of CVD among women with an infertility diagnosis, compared to women without an infertility diagnosis. All analyses were adjusted for educational attainment., Participants/materials, Setting, Methods: Female infertility and the reason for infertility was diagnosed and registered in the IVF register by specialists in Danish public and private fertility clinics since 1st of January 1994. In our cohort, 53 806 women (61.7%) were diagnosed with female factor infertility, while 33 415 (38.3%) did not have a female factor infertility diagnosis and made up the reference group., Main Results and the Role of Chance: A total of 686 (1.3%) infertile women were hospitalized for CVD compared to 250 (0.7%) among women without an infertility diagnosis during a mean follow-up time of 9 years. We found no increased risk of early CVD in our analyses (adjusted HR 0.98, 95% CI: 0.85;1.14). Likewise, analyses stratified by specific infertility diagnosis, showed no risk difference., Limitations, Reasons for Caution: We were unable to adjust for confounding parameters such as body mass index, cigarette smoking or alcohol consumption. These results may not be generalizable to infertile women who do not seek out fertility treatment, or infertile women with other lifestyle characteristics than Danish women., Wider Implications of the Findings: Diagnosing female infertility or the time of MAR does not seem to be a window of opportunity where early screening for cardiovascular disease risk factors can have a prophylactic potential., Study Funding/competing Interest(s): This study is part of the ReproUnion collaborative study, co-financed by the European Union, Interreg V ÖKS. None of the authors declare any conflict of interest., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For permissions, please e-mail: journals.permission@oup.com.)

Background: It is hypothesised that hostility accentuates the association between stressful conditions and health. This study aims to test this hypothesis by analysing the joint effect of unemployment and hostility on all-cause mortality among men and women., Methods: The population was 3677 men and 4138 women from the Danish workforce who participated in a survey in 2000. The joint exposure variable was defined as 1) employed, not hostile, 2) unemployed, not hostile, 3) hostile and employed, 4) unemployed and hostile. Outcome was defined as all-cause mortality between 2000 and 2014. Data was analysed with Cox proportional hazards models with age as the underlying time scale. The interaction between unemployment and hostility was studied using the synergy index., Results: Compared to employed non-hostile men, men who were both hostile and unemployed were at markedly higher risk of premature death with a hazard ratio (HR) of 3.19 (95% CI 2.22-4.69). A similar picture was found for hostile and unemployed women, with a HR of 1.97 (95% CI 1.24-3.12). However, the mortality in men and women exposed to both did not exceed what was expected from the combination of their individual effects. Hence, we did not find that hostility enhances the association between unemployment and all-cause mortality., Conclusion: Men and women exposed to both unemployment and hostility were at markedly high risk of premature mortality. However, this study did not support the hypothesis that the deleterious health effect of the combination of unemployment and hostility exceeds their individual effects.

Objective: To examine sociodemographic characteristics, family backgrounds, reproductive histories, and attitudes towards motherhood in single vs. cohabiting women seeking treatment with donor semen., Design: Baseline data collection in a multicenter cohort study., Setting: All nine public fertility clinics in Denmark., Sample: In total n = 311 childless women initiating assisted reproduction using donor semen., Methods: Self-reported questionnaire responses from n = 184 single women seeking treatment by using donor semen were compared with responses from n = 127 cohabiting women., Main Outcome Measures: Sociodemographic characteristics, family backgrounds, reproductive histories, attitudes towards motherhood., Results: Single women were 3.5 years older on average when initiating treatment compared with cohabiting women. No significant differences were found regarding sociodemographic characteristics, previous long-term relationships, previous pregnancies, or attitudes towards motherhood between single women and cohabiting women. The vast majority of single women wanted to achieve parenthood with a partner, 85.8% wished to have a partner in the future, and approximately half of them preferred for a partner to take parental responsibilities., Conclusions: In this study single women seeking treatment with donor semen in the public health system did not differ from cohabiting women, except that they were older. To be a single mother by choice is not their preferred way of parenthood, but a solution they needed to accept., (© 2015 Nordic Federation of Societies of Obstetrics and Gynecology.)

Objective: To examine the costs to the public health care system of couples in medically assisted reproduction., Design: Longitudinal cohort study of infertile couples initiating medically assisted reproduction treatment., Setting: Specialized public fertility clinics in Denmark., Sample: Seven hundred and thirty-nine couples having no child at study entry and with data on kind of treatment and live birth (yes/no) for each treatment attempt at the specialized public fertility clinic., Methods: Treatment data for medically assisted reproduction attempts conducted at the public fertility clinics were abstracted from medical records. Flow diagrams were drawn for different standard treatment cycles and direct costs at each stage in the flow charts were measured and valued by a bottom-up procedure. Indirect costs were distributed to each treatment cycle on the basis of number of visits as basis. Costs were adjusted to 2012 prices using a constructed medical price index., Main Outcome Measures: Live birth, costs., Results: Total costs per live birth in 2012 prices were estimated to 10,755€. Costs per treated couple - irrespective of whether the treatment was terminated by a live birth or not - were estimated at 6607€. Costs per live birth of women <35 years at treatment initiation were 9338€ and 15,040€ for women ≥35 years., Conclusion: The public costs for live births after conception with medically assisted reproduction treatment are relatively modest. The results can be generalized to public fertility treatment in Denmark and to other public treatment settings with similar limitations in numbers of public treatment cycles offered., (© 2013 Nordic Federation of Societies of Obstetrics and Gynecology.)

Objective: To investigate the independent and combined associations between female and male body mass index (BMI) on the probability of achieving a live birth after treatments with in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) under adjustment for relevant covariates., Design: Population-based cohort study., Setting: Danish national registers., Patient(s): Patients with permanent residence in Denmark receiving IVF or ICSI treatment with use of autologous oocytes from January 1, 2006, to September 30, 2010., Intervention(s): None., Main Outcome Measure(s): Live birth. Analyses were adjusted for age and smoking at treatment initiation and results stratified by BMI groups and presented by IVF/ICSI treatment., Result(s): In total, 12,566 women and their partners went through 25,191 IVF/ICSI cycles with 23.7% ending in a live birth. Overweight and obese women with regular ovulation had reduced odds of live birth (adjusted OR 0.88, 95% CI 0.79-0.99 and adjusted OR 0.75, 95% CI 0.63-0.90, respectively) compared with normal-weight women. IVF-treated couples with both partners having BMI ≥25 kg/m(2) had the lowest odds of live birth (adjusted OR 0.73, 95% CI 0.48-1.11) compared with couples with BMI <25 kg/m(2). BMI showed no significant effect on chance of live birth after ICSI., Conclusion(s): Increased female and male BMI, both independently and combined, negatively influenced live birth after IVF treatments. With ICSI, the association with BMI was less clear., (Copyright © 2013 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Study Question: Do social support and social strain from social relations have an impact on the decision to terminate fertility treatment among men and women after 1 year of unsuccessful treatment?, Summary Answer: Several functional aspects of social relations show an impact on the probability to terminate treatment; social support from family significantly decreases the probability to terminate and experience of conflicts or problematic communication with the partner significantly increases the probability to terminate treatment., What Is Known Already: Fertility patients can experience psychological, physical and economical strain as consequences of infertility and fertility treatment, and previous studies have shown that these pressures increase the probability of deciding to terminate treatment before the treatment options are exhausted. Some studies have indicated that social relations can also have an effect., Study Design, Size, Duration: This study is part of the prospective Infertility Cohort from the Copenhagen Multi-centre Psychosocial Infertility Research Programme. Baseline data were collected during January 2000-August 2001 among patients recruited at five Danish fertility clinics during their initial visit and follow-up data were collected after 1 year., Participants/materials, Setting, Methods: The study group (n = 777; 427 women, 350 men) consisted of patients who did not achieve a live birth or an ongoing pregnancy during follow-up. Social support and strain from the patients' partner, family, family-in-law, friends and colleagues were measured at baseline and the decision to terminate treatment while treatment options were not yet exhausted was measured as the outcome at the 1-year follow-up., Main Results and the Role of Chance: At the 1-year follow-up, 23% of the study group had decided to terminate treatment. For women, low levels of family support, specifically with regard to infertility, were associated with the termination of treatment after 1 year [odds ratio (OR) 6.1, 95% confidence interval (CI) 2.2-16.8] and, for men, low levels of general family support had a similar impact (OR 2.6, 95% CI 1.0-7.0). For men, difficulties in communicating with their partner about the infertility increased the probability of terminating the treatment (OR 2.3, 95% CI 1.2-4.1) and, for women, frequent conflicts with their partner increased the probability of terminating the treatment (OR 12.4, 95% CI 2.9-54.1). For women, conflicts with friends were also a predictor of treatment termination (OR 2.2, 95% CI 1.2-4.2)., Wider Implications of the Findings: Functional aspects of social relations have an impact on the decision to terminate fertility treatment among men and women. The findings in this study provide new insights into how the close social environment can have implications for men and women going through fertility treatment., Funding: This study has received support from the Danish Health Insurance Fund (J.nr. 11/097-97), the Else and Mogens Wedell-Wedellsborgs Fund, the manager E. Danielsens and Wife's Fund, the merchant L.F. Foghts Fund, the Jacob Madsen and Wife Olga Madsen's Fund, and the Engineer K.A. Rohde and Wife's Fund. The authors have no conflicts of interest to declare.

Objectives: Idiopathic environmental intolerance (IEI) is a disorder characterized by non-specific symptoms attributed to common airborne chemicals. Increasing evidence points to an association between IEI and symptoms of psychological distress. However, whether other risk factors influence this association has not been clarified. The objective of this study was to examine the association between psychological distress and IEI and to determine whether the association is confounded by social support and major life events., Methods: Data were collected by postal questionnaires; other results from the study have been published previously in this journal. The study included participants from a general population-based study who had reported symptoms of chemical sensitivities (n = 787) and two patient groups. The first patient group (n = 101) included individuals who had contacted the Danish Research Centre for Chemical Sensitivities, and the second included individuals who had been diagnosed with environmental intolerance (n = 136). Multiple, hierarchical linear regression analyses were conducted with four IEI-related domains, i.e., mucosal and CNS symptoms, chemical intolerances and social consequences, as the dependent variables, and psychological distress, social support and major life events as the independent variables., Results: Our study confirmed positive and statistically significant associations between psychological distress and IEI. The associations remained statistically significant after adjusting for major life events and social support., Conclusions: The results suggest that the association between IEI and psychological distress cannot be explained by known risk factors. More studies, including longitudinal studies, are needed to determine the role of psychological distress in the development and course of IEI.

Background: Most studies on disclosure of mode of conception after fertility treatment have focused on donor insemination. We present a large, longitudinal cohort study of fertility patients who conceived through a variety of fertility treatments, including both non-donor and donor techniques., Methods: A cohort of 2812 women and men (n = 1406 couples) received questionnaires when initiating fertility treatment and at 1-year and 5-year follow-ups. At the 5-year follow up, the response rate was 69.4% and 1036 of the responding participants had at least one child born after fertility treatment. Around 66% of the children were conceived with in vitro fertilization or intrauterine insemination with partners semen, 26% with intracytoplasmic sperm injection, 7% with donor gametes and <1% with other treatments. The parents were asked whether they already had or intended to disclose the conception method to the child and to others. We used logistic regression to identify determinants among women and men for disclosure., Results: Most of the parents had disclosed or intended to disclose the mode of conception to the child, and almost everyone had disclosed to someone else. Not having used donor gametes was a significant determinant of disclosure both to the child and to other people among women and men. Having disclosed to other people was a significant predictor for having disclosed or intending to disclose to the child. Among women, low social class was a significant determinant of disclosure to the child. Among men, satisfaction with the medical treatment was a significant determinant of disclosure to other people., Conclusions: We found a large majority who had or intended to disclose to the child how he/she was conceived. Non-disclosure was significantly related to the use of donor gametes.

Clinically a couple is considered to be infertile after at least one year without contraception and without pregnancy. There was scant knowledge about the prevalences of infertility, involuntary childlessness and the seeking of fertility treatment and only few longitudinal studies about the psychosocial consequences of infertility and its treatment. This thesis is about the epidemiological aspects of infertility; the conceptualization and measurement of important psychosocial aspects of infertility; and a medical sociological analysis of the associations between these psychosocial variables among Danish women and men in fertility treatment. The thesis is based on nine papers. The three main purposes were: (i) to review critically, population based studies of infertility and medical care seeking in industrialised countries. Further, to examine these prevalences and subsequent motherhood among women in former assisted reproduction in a Danish population. (ii) To develop measures of psychosocial consequences of infertility: fertility problem stress, marital benefit, communication, coping strategies, attitudes to and evaluation of fertility treatment. (iii) To examine these phenomena and to analyse their interrelations among Danish women and men in fertility treatment. The thesis is based on four empirical studies: (i) The Women and Health Survey, a cross-sectional population-based study among 15-44 year old women (n=907, 25-44 year old) in Copenhagen County, 1989. (ii) The Psychosocial Infertility Interview Study, a qualitative interview study among 16 couples (n=2 participants) infertility treatment at The Fertility Clinic, Herlev University Hospital,1992. (iii) The Infertility Cohort, a longitudinal cohort study consecutively including all couples (n=250 participants) beginning anew fertility treatment period at one of four public (Braedstrup, Herlev, Odense, Rigshospitalet) and one private fertility clinic (Trianglen),2000-2002. (iv) The Communication and Stress Management Training Programme, an intervention study among couples(n=74 participants) in fertility treatment at The Fertility Clinic, The Juliane Marie Centre, Rigshospitalet, 2001-2003. Included is also a literature review of population-based infertility studies from industrialised countries. Data from (iii) and (iv) are studies from The Copenhagen Multi-centre Psychosocial Infertility (COMPI) Research Programme (www.compipro.dk). Epidemiological and demographic studies investigating the prevalences of infertility differed in how they defined the numerator (the infertile participants) and the denominator (the population at risk). It was important to calculate reliable estimates of the infertility prevalence by including only women who had tried to have at least one child in the population at risk, as a notable proportion of women in the fertile ages had not (yet) attempted to become a mother. The lifetime prevalence of infertility in the representative population-based study was 26.4%. In the age group 35 to 44 years 5.8% were primarily involuntarily in fecund (involuntarily childless). Even in a country with access to fertility treatment in a public health-care system without self-payment lower education was a predictor of lower treatment seeking. In the cohort study (2000-2002)of couples starting a new period of assisted reproduction treatment 62.6% reported a treatment-related pregnancy at the one-year follow-up. In total 32.4% reported a treatment-related delivery. In total 24.2% reported a current continuing pregnancy and spontaneous pregnancies accounted for 2.7% of these. We developed measures of fertility problem stress, marital benefit(that infertility has brought the partners closer together and strengthened their marriage), partner communication, infertility related communication, coping strategies, attitudes to fertility treatment and evaluation of care. The medical sociological analyses showed that the variables of psychosocial consequences of infertility and treatment are interwoven with each others in a complex pattern, a pattern that both differed and was similar when comparing women and men. The infertility-related communication strategy (secrecy, formal, open-minded)identified in the qualitative interviews was later confirmed in the COMPI Infertility Cohort. Using the formal strategy and not talking about the emotional aspects of infertility and its treatment suggested high fertility problem stress. The coping strategies studied showed significant social differences and active-avoidance coping was a significant predictor of high fertility problem stress. A positive effect of infertility on the marriage, marital benefit was common. Men using the secrecy communication strategy had increased risk of low marital benefit. Difficult partner communication was a significant predictor of high fertility problem stress and among men, of low marital benefit. The intervention study showed that it was possible for the participants to change their communication with partner and other people close to them and that participants achieved an increased awareness of what, how much and when to discuss with others. High fertility problem stress and high marital benefit were associated with high importance ratings of patient-centred care and intentions to use professional psychosocial services. Among women, high fertility problem stress was a predictor of lower satisfaction ratings with fertility treatment. High marital benefit was a predictor of high satisfaction ratings of both medical and patient-centred care. In conclusion, infertility is a common experience among couples attempting to become parents. Assisted reproduction in the public health-care system in Denmark has high success rates, i.e. pregnancies,deliveries and high patient satisfaction. A large minority of people in fertility treatment experience high fertility problem stress,and some use communication and coping strategies that predicts high stress. Developing and evaluating different psychosocial interventions are necessary to offer the psychosocial support needed for this minority of fertility patients.

Objective: To investigate (i) marital benefit, e.g., that infertility has strengthen the marriage and brought the partners closer together among people beginning fertility treatment and (ii) communication and coping strategies as predictors of marital benefit 12 months later., Methods: A prospective cohort design including 2250 people beginning fertility treatment and a 12-month follow-up. Data were based on self-administered questionnaires measuring marital benefit, communication, and coping strategies. The analyses of predictors were based on the sub-cohort (n=816) who had not achieved a delivery after fertility treatment., Results: 25.9% of women and 21.1% of men reported high marital benefit. Among men medium use of active-confronting coping (e.g., letting feelings out, asking others for advice) and use of meaning-based coping were significant predictors for high marital benefit. Having the infertility as a secret, difficult marital communication, and using active-avoidance coping (e.g., avoid being with pregnant women or children, turning to work to take mind off things) were among men significant predictors for low marital benefit. No significant predictors were identified among women., Conclusion: Fertility patients frequently experience marital benefit., Practice Implications: The study provides information about where to intervene with male fertility patients in order to increase their marital benefit after medically unsuccessful treatment.

Currently 4% of the Danish national birth cohort is born after in vitro fertilisation techniques and almost 40% of these children are twins. In this register-based national cohort study, twins from assisted conception (n = 3393) had a similar risk of neurological sequelae and cerebral palsy as their naturally conceived peers (n = 10.239) and assisted conceived singletons (n = 5130). Further children born after intracytoplasmic sperm injection (ICSI) had the same risk of neurological sequelae as children born after conventional IVF.

Background: Palliative home-care teams often cooperate with general practitioners (GPs) and district nurses. Our aim was to evaluate a palliative home-care team from the viewpoint of GPs and district nurses., Methods: GPs and district nurses received questionnaires at the start of home-care and one month later. Questions focussed on benefits to patients, training issues for professionals and cooperation between the home-care team and the GP/ district nurse. A combination of closed- and open-ended questions was used., Results: Response rate was 84% (467/553). Benefits to patients were experienced by 91 %, mainly due to improvement in symptom management, 'security', and accessibility of specialists in palliative care. After one month, 57% of the participants reported to have learnt aspects of palliative care, primarily symptom control, and 89% of them found cooperation satisfactory. Dissatisfaction was caused mainly by lack of information from the home-care team to primary-care professionals., Conclusion: GPs and district nurses welcomed the palliative home-care team and most experienced benefits to patients. Strengthened communication, initiated by the home-care team would enhance cooperation.

Objective: To compare neurological sequelae in twins born after assisted conception with singletons after assisted conception and naturally conceived twins and to assess neurological sequelae in children conceived after in vitro fertilisation (IVF) compared with intracytoplasmic sperm injection (ICSI)., Design: Controlled, national register based, cohort study., Participants: Twins (n = 3393) and singletons (n = 5130) conceived by using assisted reproductive technologies and naturally conceived twins (n = 10 239) born in Denmark between 1995 and 2000. The children's age at time of follow up was 2-7 years., Data Sources: Children were identified by cross linkage of the national medical birth registry and the national registry for in vitro fertilisation. Neurological and psychiatric diagnoses were retrieved from the national patients' registry and the Danish psychiatric central registry., Main Outcome Measures: Neurological sequelae, defined as cerebral palsy, mental retardation, severe mental developmental disturbances, and retarded psychomotor development. Further we made separate analyses on the specific cerebral palsy diagnosis., Results: The crude prevalence rates per 1000 of neurological sequelae in twins and singletons after assisted conception and in naturally conceived twins were 8.8, 8.2, and 9.6, and of cerebral palsy 3.2, 2.5, and 4.0, respectively. In twins after assisted conception compared with control twins, the odds ratios of neurological sequelae and specifically of cerebral palsy, adjusted for child sex and year of birth, were 0.9 (95% confidence interval 0.6 to 1.4) and 0.8 (0.4 to 1.6), respectively. The corresponding odds ratios for twins after assisted conception compared with singletons after assisted conception were 1.1 (0.7 to 1.7) for neurological sequelae and 1.3 (0.6 to 2.9) for cerebral palsy. The odds ratio of neurological sequelae in children conceived by ICSI was 0.9 (0.5 to 1.7) nu children conceived by IVF., Conclusions: Twins from assisted conception have a similar risk of neurological sequelae as their naturally conceived peers and singletons from assisted conception. Children born after ICSI have the same risk of neurological sequelae as children born after IVF.

Background: In Denmark, one-third of twin pregnancies are the result of IVF/ICSI treatment. Limited data on neonatal outcome in IVF/ICSI twins are available in the literature., Methods: A register study was conducted on neonatal morbidity and mortality in a complete national twin cohort including all 3438 (3393 live-born) IVF/ICSI and 10,362 (10,239 live-born) non-IVF/ICSI twins born between 1995 and 2000. Twins were identified in the National Medical Birth Registry and dichotomized into IVF/ICSI and non-IVF/ICSI by cross-reference with the Danish IVF Registry. Data on neonatal morbidity and mortality were retrieved from the Danish Patient Registry and the Danish Registry of Causes of Deaths. In order to exclude monozygotic twins, sub-analyses on unlike-sex twins were conducted., Results: A birth weight discordance of >20% was observed in 20.6% of IVF/ICSI versus 15.7% of control twin pairs (P < 0.001). The risk of discordant birth weight >20% was OR 1.29 (95% CI 1.04-1.58) in unlike-sex IVF/ICSI twins versus control twins. The risk of delivery at <37 completed weeks and birth weight <2500 g was similar in the two cohorts; however, in unlike-sex IVF/ICSI versus control twins the risk of delivery at <37 weeks and birth weight <2500 g was OR 1.22 (95% CI 1.09-1.38) and OR 1.25 (1.11-1.40) respectively. After stratification for maternal age and parity, these risks disappeared. IVF/ICSI twins carried a higher risk of admittance to a neonatal intensive care unit (NICU) than control twins (OR 1.18, 95% CI 1.09-1.27), and this was even more pronounced in unlike-sex twins [OR 1.34 (95% CI 1.19-1.51)]. No differences were observed in malformation or mortality rates between the two cohorts., Conclusions: Despite higher birth weight discordance and more NICU admissions among IVF/ICSI twins, neonatal outcome in IVF/ICSI twins seems to be comparable with that of non-IVF/ICSI twins, when only dizygotic twins were considered in the comparisons.