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Infertility is a medical diagnosis impacting 48 5 million couples globally Infertility impacts physical and emotional health as well as social and romantic relationships People with infertility report feelings of distress, grief, anxiety and depression Couples notice changes in their relationships;some report becoming emotionally closer while others report relationship difficulties People may feel more isolated due to lack of social support People that use third party reproduction, such as donor egg, sperm, embryo or gestational carriers, have additional emotional impacts during pregnancy and parenting Continuing changes to laws complicate international fertility care, particularly given the ongoing COVID‐19 pandemic

To evaluate the medical student perception of unprofessional experiences on the obstetrics and gynecology clerkship through evaluation of reflective essays using qualitative research and grounded theory. All third year medical students rotating through OBGYN were required to write an essay on an experience they had with positive and/or negative professionalism during their clinical rotation. Essays were analyzed from a total of 220 students and coded into eight domains with subcategories. Inter-rater reliability was established with two of the coders (MR and BG) with high levels of correlation kappa’s agreement 0.73 CI (0.57, 0.88). Qualitative analysis using grounded theory was deployed for essay theme analysis. Frequencies were used for descriptive purposes. Most students chose to write about incidents of negative professionalism that they observed. The most common domain themes were medical team dynamics (19%), inpatient interactions (20%), and inappropriate remarks about a patient (16%). A quarter (26%) of the essays also included an observation of a positive demonstration of professionalism. Students frequently report experiencing mistreatment through the perception of a hostile learning environment. The essays described frequent exposure to unprofessional actions that can create a hostile learning environment and thus potential mistreatment. The students frequently wrote about witnessing unprofessional comments made by team members about patients, residents, and other students. All medical educators need to work to reduce student mistreatment through reducing unprofessional behavior.

OBJECTIVE: To ascertain the strength of association between dispositional optimism, assessed with the Revised Life Orientation Test (LOT-R), and obstetrical outcomes, and to evaluate women's social characteristics that may lead to low dispositional optimism during pregnancy. STUDY DESIGN: The research was conducted using MEDLINE, EMBASE, Scopus, Web of Sciences, Cochrane Database, and ClinicalTrial.gov as electronic databases. The articles were identified with the use of a combination of the relevant heading term, key words, and word variants for: "optimism" or "happiness" and "pregnancy" or "obstetrical outcomes", from the inception of each database to June 2019. Review of articles also included the abstracts of all references retrieved from the search. Randomized, cohort, case-control, or case series were all accepted study designs. Only studies reporting obstetrical outcomes in women undergone LOT-R to assess dispositional optimism during pregnancy were included. Obstetrical outcomes included preterm birth, pre-eclampsia and small for gestational age fetuses. All analyses were carried out using the random effects model. Dichotomous variables were analyzed using the odds ratio (OR) with a 95 % confidence interval (95 % CI). No continuous variables were compared in the analysis. Significance level was set at P < 0.05. Heterogeneity was measured using I-squared (Higgins I2). RESULTS: Two prospective cohort studies, including 3,570 pregnancies undergone LOT-R - mostly during the second trimester - were included in the systematic review. Out of the 3,570 pregnancies included, 411 were in the lowest quartile of optimism, according to LOT-R score. Dispositional optimism showed a trend towards lower incidence of preterm birth (7.6 % vs 9.7 %; OR 0.76, CI 0.53-1.09); no difference between women at higher levels and women in the lowest quartile of optimism was found in preeclampsia and small for gestational age. Women at higher levels of dispositional optimism were significantly associated with: age ≥ 30 years; marriage or "marriage-like status"; lower rates of public assistance and smoking; white ethnicity; higher rates of higher education. CONCLUSION: There are limited data on optimism and obstetric outcomes. Higher levels of optimism, evaluated by the LOT-R tool in two studies, are associated with a non-significant decrease in preterm birth.

The role of mental health professionals (MHPs) in third-party reproduction has grown and evolved in service to patient care and the needs of medical infertility practices. The need for mental health evaluation and psychoeducation has increased as the psychosocial considerations for the stakeholders and families created through gamete donation and surrogacy are increasingly understood and considered. The conflicting definitions of these roles of evaluation and psychoeducation often leave MHPs in the role of de facto ethical gatekeepers in third-party reproduction. Both the medical team and the MHP need to clarify their role effectively, for themselves, as well as any intended parent.

Infertility and recurrent pregnancy loss after infertility are increasingly recognized as experiences encompassing not only medical but also emotional, cognitive, economic, spiritual, and social realms for patients. Keeping pace with developments in reproductive medicine, psychological research regarding infertility and recurrent pregnancy loss has focused on the associated psychosocial factors and the impact of these factors on treatment and outcomes. This review of the psychological research reveals that the impact of the psychosocial functioning and mental health of infertility patients during all phases of treatment is far-reaching, influencing treatment initiation, dropout rates, treatment compliance, and the pursuit of psychological services and other interventions such as psychotropic medication. Knowledge of these psychosocial factors, along with the provision of psychological screenings and interventions, has the potential to positively impact outcomes for infertility patients, including those experiencing repeated implantation failure or pregnancy loss.

Objectives Acquiring communication and interpersonal skills is an important part of providing patient-centered care and improving patient satisfaction. This study explores whether residents' own values about patient communication can be influenced by training. Methods As part of service excellence, a three-hour communication skills training in AIDET™ (Acknowledge, Introduce, Duration, Explanation, Thank You) was delivered to first and second Post-Graduate Year (PGY) residents (n = 123). A survey was designed to measure the value of patient communication and administered pre/post communication skills training. Results Residents' scores about communication values improved significantly for all areas pre- to post-training for patient communication skills (pConclusions Residents value communication, and AIDET™ training is a useful tool to increase the values of good communication and interpersonal skills to enhance service excellence.

How old is too old to be a father? Can you be a little bit older or "old-ish" to be a dad without being considered an "older dad"? At some point, does one simply become too old to be a father? Unless a man requires medical assistance in family building, that answer has historically turned solely on his opportunity to have a willing female partner of reproductive age. As with so many other aspects of family building, assisted reproductive technologies have transformed the possibilities for-and spawned heated debates about-maternal age. Much attention has been given to this contentious topic for potential mothers, with many programs putting age-related limitations in place for their female patients. This article considers whether there should also be limits-and how we should approach that question-for men who require and seek medical assistance to become fathers.

The use of intrafamilial gamete donors and surrogates is generally ethically acceptable when all participants are fully informed and counseled, but arrangements that replicate the results of true consanguineous or incestuous unions should be prohibited, child to parent arrangements are generally unacceptable, and parent to child arrangements are acceptable in limited situations. Programs that choose to participate in intrafamilial arrangements should be prepared to spend additional time counseling participants and ensuring that they have made free, informed decisions.

Mental health professionals serve an important role in guiding intended parents through a myriad of considerations from donor or surrogate selection to issues of disclosure with children. This role has evolved due to many considerations including evolving practice and ethics guidelines, as well as other factors such as access to the internet. This Views and Reviews will explore how team care, inclusive of the mental health professional, serves the interests of patients and provides a strong foundation for families created with the help of donors and/or surrogates.

Introduction : Sexual dysfunction can be a silent partner of infertility treatment. Rarely is sexual dysfunction the cause of infertility. More often, sexual dysfunction is a consequence of the infertility experience and/or treatment. Sexual intimacy is profoundly affected by infertility sequelae, such as lowered self-esteem, depressive or anxiety feelings, and association of sexual intimacy with failure to procreate. Methods : The definition of primary sexual dysfunction is made by diagnosing a problem that has always existed. Secondary sexual dysfunction denotes situations in which a problem develops after an individual has had normal sexual function. Infertility, already a series of many losses for many couples, will create a loss of sexual intimacy and enjoyment. Treatment demands, e.g. producing semen specimens or timed intercourse, may also create disruption or dysfunction. Results : Sexual dysfunction can be treated to enhance both infertility treatments and dyadic adjustment. There are many treatment approaches that may include medical intervention, counseling and behavioral techniques. Conclusion : Clinicians practicing in the field of infertility need to bring heightened awareness to their patients’ sexual function. Acknowledging that sexual function is a valued part of relationship, apart from the need to conceive, can give couples permission to address this sensitive area of their relationship.

Purpose : This study was designed to compare levels of satisfaction for ovum donors and gestational carriers/surrogates (GCS), investigate attitudes, and explore beliefs about the role genetics, gestation, and environment play in various characteristics. Design : An east coast IVF center and two California-based agencies recruited donor and GCS candidates. Methods : Participants received mailed questionnaires that included sections on demographics, attitudes, and beliefs. Results : Both groups were highly satisfied with their participation. Donors were not willing to be GCS, and GCS were not willing to be donors. GCS thought about and disclosed their participation, felt children should be told about GCS, and desired future contact with the child(ren) more than did donors (p < 0.002). Donors did not indicate a preference about disclosure. Contact with recipients did not correlate with satisfaction. Conclusion : Women who chose to donate eggs or to be GCS hold distinct and different beliefs about the role of gestation and genetics.

Mental health professionals serve an important role in guiding intended parents through a myriad of considerations from donor or surrogate selection to issues of disclosure with children. This role has evolved due to many considerations including evolving practice and ethics guidelines, as well as other factors such as access to the internet. This Views and Reviews will explore how team care, inclusive of the mental health professional, serves the interests of patients and provides a strong foundation for families created with the help of donors and/or surrogates.

Our aim was to assess the psychologic characteristics and postdonation satisfaction of anonymous oocyte donors. Twenty-five consecutive anonymous oocyte donors completed psychologic tests before donation and satisfaction ratings following completion of the egg donation cycle. The average donor was 27 years old, married, and employed outside the home. All predonation scores on the psychologic measures were within the normal range. However, 24% of donors reported a history of sexual assault, and 40% described having had some type of reproductive loss. Although monetary compensation for donation was provided, altruism was reported as the most salient motivating factor. Following oocyte donation, 80% of women stated that they would be willing to donate again. Postdonation satisfaction was high. A significant negative correlation was found between predonation financial motivation and postdonation satisfaction (r = -.48, p < 0.01) and between predonation ambivalence and postdonation satisfaction (r = -.84, p < 0.0001). Donors with high levels of predonation financial motivation or ambivalence should be carefully screened and counseled before oocyte donation to ensure satisfactory psychologic outcome.

Columbia d Jefferson Medical College, Philadelphia, Pennsylvania Redshift Technologies, New York, New York New York-Presbyterian/Weill Cornell, New York, New York g South Florida Institute for Reproductive Medicine, Miami, Florida h Spence & Elster, PC, Chicago, Illinois Reproductive Biology Associates, Atlanta, Georgia Harvard School of Public Health, Boston, Massachusetts k Seattle Reproductive Medicine, Seattle, Washington Center for Reproductive Medicine and Infertility, New York, New York

Allusions to third-party reproduction have existed since biblical times when Sarah and Abraham used Hagar as their surrogate to beget Ishmael. Surrogacy has come a long way since then; today it is a global business. Sperm donation has also been used since biblical days and has since evolved into a multimillion-dollar industry. Ovum donation is a relative newcomer to third-party reproduction, but its use has grown quickly since its introduction in the 1980s.

Objective To survey fertile and infertile individuals concerning attitudes about donor insemination and ovum donation and to analyze whether gender, experience with infertility, and religion influences: [1] preference for choosing gamete donor over adoption or child-free living; [2] choice of selecting a known or anonymous donor; or [3] choice of disclosure or nondisclosure to any offspring. Design Patients in an infertility clinic and obstetrics and gynecology practice were asked to complete surveys. Participants Three hundred nineteen individuals who completed surveys. Main Outcome Measures A 14-item questionnaire (created for this study) with a demographic information section. Results No gender differences were observed for preference to use donor gametes, to adopt, or to live child free within the infertility group. In the obstetrics and gynecology group, men preferred adoption more than women and were less likely to use a donor. Choice of whether to use a donor, which donor source, and whether to disclose the use of a donor was influenced by gender, experience with infertility, and religion. Conclusions Gender, experience with infertility, and religion influence an individual's choice in family building options as well as what information will be shared with the child. There is a wider acceptance of using known donor sources than has heretofore been seen and these options should be explored.

What are single parents by choice? Single parents by choice (SPCs) are single men (single fathers by choice), or women (single mothers by choice), who actively choose to parent a child without a partner. The term single mother by choice (SMC) has been used to describe a distinct group of women who differ in a number of ways from mothers who either conceive accidently or become single after separation or divorce (Chan et al ., 1998; Mannis, 1999; Murray and Golombok, 2005a, 2005b). They are often older women, predominantly heterosexual, in their thirties and forties, well educated and financially independent (Murray and Golombok, 2005a, 2005b; Hertz, 2006; Jadva et al ., 2009a). There is currently a dearth of academic literature concerning single fathers by choice (SFCs) and little is known about such men or the children they raise. Routes to single parenthood by choice An SPC decides to have a child knowing that they will parent that child, at least initially, without a partner. This can be achieved via various routes and does not necessarily have to incorporate the use of Assisted Reproductive Technologies (ARTs). A woman could embark upon single motherhood by choice through sexual intercourse, donor insemination (DI) at a clinic, self-insemination with a known or anonymous donor, as well as through adoption or fostering (Bock, 2000; Hertz, 2006). Research has shown that different women choose different methods depending upon their circumstances, the options available to them and their beliefs about the morality of different methods. For example, some women may feel it is wrong to deceive a man by purposefully getting pregnant through a sexual encounter (Bock, 2000; Murray and Golombok, 2005a) while others feel that adoption is a morally superior route to single motherhood (Mannis, 1999; Morrissette, 2008). However, for many women adoption is seen as a last resort (Hertz, 2006), wanting instead to experience pregnancy and have genetically related children. Indeed, Jadva et al . (2009a), in their survey of 291 women using the US-based website ‘choice moms’, found that the most common method used to become an SMC was DI at a clinic: single motherhood by choice was most commonly pursued through the use of ARTs.

This document presents arguments that conclude that it is unethical to use somatic cell nuclear transfer (SCNT) for infertility treatment due to concerns about safety; the unknown impact of SCNT on children, families, and society; and the availability of other ethically acceptable means of assisted reproduction. This document replaces the ASRM Ethics Committee report titled, "Human somatic cell nuclear transfer (cloning)," last published in Fertil Steril 2000;74:873-6.

Medical providers have an ethical duty to immediately disclose clinical errors involving gametes or embryos; clinics should have written policies in place for reducing and disclosing errors. This document was reviewed and affirmed in 2011 and replaces the earlier document of the same name.

Objective To investigate how many programs currently have an ovum donor program and to examine the current state of the art in ovum donor programs regarding management, screening, and implementation. Design Surveys were sent to members of the Society for Assisted Reproductive Technology (SART) and the Psychological Special Interest Group of the American Fertility Society. Results Of 160 SART members, 82 surveys were returned. Psychological Special Interest Group surveys were excluded. A trend toward more third party reproduction was seen. There was little uniformity among programs regarding medical or psychological screening. Differences were seen between the screening and administration of ovum and sperm donation. Conclusions Unlike sperm donation, ovum donation has begun in the known donor realm. Medical and psychological screening is currently limited in many ovum donor programs and highly variable with both known and anonymous donors. Most programs do use a mental health person as part of the screening process. More guidelines are needed to provide uniformity for the current practice of ovum donation.

Objective To explore assisted reproductive technology (ART) programs' beliefs about and practices for screening program candidates for the use of ART services. Design An anonymous, self-administered, mailed questionnaire. Setting U.S. ART programs. Participant(s) Directors of U.S. ART programs. Main outcome measure(s) Screening practices and beliefs, agreement with statements about screening rights and responsibility, information collected about candidates, and likelihood of turning away hypothetical candidates. Result(s) The majority of programs do not have a formal policy for screening candidates. The majority of program directors agree that they have a right and responsibility to screen candidates. On average, programs turn away 4% of candidates each year. The majority of programs report being very to extremely likely to deny treatment to the couples described in various scenarios, such as physical abuse, positive HIV status, and single parenthood. Significant variation was seen across programs in their likelihood of turning away various hypothetical candidates. Conclusion(s) There is substantial variation in ART programs' screening practices. These results highlight the need for increased debate over what constitutes inappropriate denial of access to services, and what are prudent, social, ethical, and medical judgments.

Objective: To explore the medical issues, attitudes, concerns, and choices that parents have about their children born with the use of assisted reproductive technology (ART). Design: Retrospective and prospective survey. Setting: An academic medical center and a private practice. Patient(s): Participants who conceived and were delivered of infants in two ART programs. Intervention(s): A total of 373 patients were mailed an anonymous survey, a consent form, and the Parent Child Relationship Inventory. The rate of response was approximately 49% for clinic A and 33% for clinic B. Main Outcome Measure(s): Pregnancy outcomes and attitudes about parenting. Result(s): Respondents' major concerns during pregnancy revolved around miscarriage and the infant's health; complications occurred in 38.9% of first pregnancies. Parents believed that their children were more appreciated, that their children were not emotionally different, that ART did not create ongoing medical or emotional problems, and they were not overprotective as parents. Gender differences were statistically significant on attitudinal variables. Conclusion(s): Parents had concerns about pregnancy. Overall, men and women felt positive about ART and their parenting. The ART experience is associated with complex choices, attitudes, and emotions.

Objective: To evaluate the results of a gestational carrier program in terms of pregnancy rates in fresh and cryopreserved cycles. Design: Retrospective analysis. Setting: Private IVF program. Patient(s): Women with uterine or medical reasons for unsuccessful gestation. Intervention(s): In vitro fertilization of oocytes with fresh or cryopreserved ET to gestational carriers. Main Outcome Measure(s): Pregnancy rates and deliveries. Result(s): A PR of 56.3% and a cycle rate of 30.8% was achieved in each patient 40 years of age in 27 cycles. Conclusion(s): Carrier gestation offers a satisfactory solution to childlessness caused by uterine or major medical factors.

In “Why Have Children? The Ethical Debate,” Christine Overall takes a critical journey through the moral issues involved in the choice to have or not have a child. Although the debate is viewed lar...

Objective To develop the first international instrument to measure fertility quality of life, FertiQoL, in men and women experiencing fertility problems, to evaluate the preliminary psychometric properties of this new tool and to translate FertiQoL into multiple languages. Design Survey. Setting Online and fertility clinics in USA, Australia/New Zealand, Canada, and United Kingdom. Participants A total of 1,414 people with fertility problems. Intervention(s) None. Main Outcome Measure(s) FertiQoL. Result(s) FertiQoL consists of 36 items that assess core (24 items) and treatment-related (10 items) quality of life as well as overall life and physical health (2 items). Cronbach reliability statistics for the Core and Treatment FertiQoL (and subscales) were satisfactory, in the range of 0.72 and 0.92. Sensitivity analyses showed that FertiQoL detected expected relations between quality of life and gender, parity, and support seeking. FertiQoL was translated into 20 languages by the same translation team, with each translation verified by local bilingual fertility experts. Conclusion(s) FertiQoL is a reliable measure of the impact of fertility problems and its treatment on quality of life. Future research should establish its use in cross-cultural research and clinical work.

Genetic parents and gestational carriers in our gestational carrier program were evaluated by psychodiagnostic interview and by the Minnesota Multiphasic Personality Interview—2 (MMPI-2), a widely used objective psychological test, to identify psychopathology and describe personality characteristics. Overall, participants exhibited no overt psychopathology. Personality differences were found between gestational carriers and genetic mothers and genetic fathers and mothers. Clinical interviews revealed that gestational carriers tended to be the dominant partner in the relationship, were motivated by a wish to help an infertile couple, enjoyed being pregnant, showed narcissistic needs, and expressed a wish for secondary financial gain. The majority of gestational carriers stated that they had considered becoming a traditional surrogate but felt they could not surrender a child that was genetically theirs. These results indicate that there is not any predisposing psychopathology which attracts participants to the gestational carrier program.

I ncreasing use of applied in vitro fertilization (IVF) technologies continues to make the seemingly simple definition of parenthood a complex and controversial subject. This discussion is intended to examine the American College of Obstetricians and Gynecologists (ACOG) committee opinion ~ concerning the development of an ethically acceptable public policy on surrogate parenting arrangements. Although we agree with the need for a revised statement of policy and guidelines for the use of "surrogate" arrangements, we strongly disagree with the committee opinion's statement that "the genetic link between the commissioning couple and the resulting infant, while important, is less weighty than the link between surrogate mother and fetus or infant that is created through gestation and birth." Linking traditional surrogate motherhood with gestational surrogate motherhood (referred to hereafter as gestational carrier) 2 only serves to confuse the latter arrangement. This is why we have stressed the term gestational carrier as a fair and easily understood description of a process that differs dramatically from surrogate parenting with respect to the source of the female genome. The ACOG committee's choice of "gestational surrogate motherhood" forces the medical community and the layperson alike to ascribe motherhood to the act of gestating. It is also important that those involved in forming social opinions and legislative policies be familiar with data available from such programs. Data from gestational carrier programs are limited, but what has been reported 3,4 serves to indicate that the potential for success with such programs is high and actual benefits outweigh potential harm. We sought acceptance and approval for the gestational carrier program at Pennsylvania Hospital from our Research Review Board, Ethics Committee, and Board of Managers in late 1988 at a time when there was great public attention and controversy over the Mary Beth Whitehead surrogacy custody case. Using the genetic source as the key determinant, the boards felt that the potential issues involving biologic parentage and parental rights were better defined with gestational carrier than with traditional surrogacy. © 1991 by The Jacobs Institute of Women's Health 1049-3867/91/$3.50

Purpose: This study was designed to compare levels of satisfaction for ovum donors and gestational carriers/surrogates (GCS), investigate attitudes, and explore beliefs about the role genetics, gestation, and environment play in various characteristics.