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To survey practice patterns designed to increase access to infertility care and evaluate the exposure of obstetrics and gynecology residents to infertility care for the underserved.Cross-sectional.Reproductive endocrinology and infertility (REI) practices associated with Accreditation Council for Graduate Medical Education-accredited obstetrics and gynecology residency training programs.None.Questionnaire survey.Presence of clinical programs designed to improve access to REI care, resident involvement in such programs, and perceived barriers to expanding access to care.Clinical initiatives to expand access included discounted infertility services (38%, n = 30), utilization of a low-cost in vitro fertilization (IVF) program (28%, n = 22), and utilization of a resident- and/or fellow-staffed clinic to provide infertility care (39%, n = 31). The most commonly discounted infertility services were IVF (73%, n = 22), clinical consultation (70%, n = 21), and intrauterine insemination (53%, n = 16). The provision of discounted prices was correlated with the increasing practice size (odds ratio [OR], 2.29; 95% confidence interval [CI], 1.23-4.24) and number of assisted reproductive technology cycles performed annually (OR, 3.65; 95% CI, 1.48-9.02). Academic REI practices (OR, 3.6; 95% CI, 0.98-13.25) were more likely to have a low-cost IVF program. Less than half of obstetrics and gynecology residency programs (39%, n = 31) had an associated REI clinic in which obstetrics and gynecology residents provide direct infertility care to the medically underserved. Frequency and services offered in trainee clinics varied. Multiple barriers to expanding access to care were reported.Reproductive endocrinology and infertility practices associated with obstetrics and gynecology residency programs utilize a diverse range of approaches to provide infertility care to the underserved in the backdrop of considerable challenges and barriers, but significant gaps persist.

STUDY QUESTION What are the direct costs of assisted reproductive technology (ART), and how affordable is it for patients in low- and middle-income countries (LMICS)? SUMMARY ANSWER Direct medical costs paid by patients for infertility treatment are significantly higher than annual average income and GDP per capita, pointing to unaffordability and the risk of catastrophic expenditure for those in need. WHAT IS KNOWN ALREADY Infertility treatment is largely inaccessible to many people in LMICs. Our analysis shows that no study in LMICs has previously compared ART medical costs across countries in international dollar terms (US$PPP) or correlated the medical costs with economic indicators, financing mechanisms, and policy regulations. Previous systematic reviews on costs have been limited to high-income countries while those in LMICs have only focussed on descriptive analyses of these costs. STUDY DESIGN, SIZE, DURATION Guided by the preferred reporting items for systematic reviews and meta-analyses (PRISMA), we searched PubMed, Web of Science, Cumulative Index of Nursing and Allied Health Literature, EconLit, PsycINFO, Latin American & Caribbean Health Sciences Literature, and grey literature for studies published in all languages from LMICs between 2001 and 2020. PARTICIPANTS/MATERIALS, SETTING, METHODS The primary outcome of interest was direct medical costs paid by patients for one ART cycle. To gauge ART affordability, direct medical costs were correlated with the GDP per capita or average income of respective countries. ART regulations and public financing mechanisms were analyzed to provide information on the healthcare contexts in the countries. The quality of included studies was assessed using the Integrated Quality Criteria for Review of Multiple Study designs. MAIN RESULTS AND THE ROLE OF CHANCE Of the 4062 studies identified, 26 studies from 17 countries met the inclusion criteria. There were wide disparities across countries in the direct medical costs paid by patients for ART ranging from USD2109 to USD18 592. Relative ART costs and GDP per capita showed a negative correlation, with the costs in Africa and South-East Asia being on average up to 200% of the GDP per capita. Lower relative costs in the Americas and the Eastern Mediterranean regions were associated with the presence of ART regulations and government financing mechanisms. LIMITATIONS, REASONS FOR CAUTION Several included studies were not primarily designed to examine the cost of ART and thus lacked comprehensive details of the costs. However, a sensitivity analysis showed that exclusion of studies with below the minimum quality score did not change the conclusions on the outcome of interest. WIDER IMPLICATIONS OF THE FINDINGS Governments in LMICs should devise appropriate ART regulatory policies and implement effective mechanisms for public financing of fertility care to improve equity in access. The findings of this review should inform advocacy for ART regulatory frameworks in LMICs and the integration of infertility treatment as an essential service under universal health coverage. STUDY FUNDING/COMPETING INTEREST(S) This work received funding from the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization (WHO). The authors declare no competing interests.

STUDY QUESTIONWhat are the direct costs of assisted reproductive technology (ART), and how affordable is it for patients in low- and middle-income countries (LMICS)?SUMMARY ANSWERDirect medical costs paid by patients for infertility treatment are significantly higher than annual average income and GDP per capita, pointing to unaffordability and the risk of catastrophic expenditure for those in need.WHAT IS KNOWN ALREADYInfertility treatment is largely inaccessible to many people in LMICs. Our analysis shows that no study in LMICs has previously compared ART medical costs across countries in international dollar terms (US$PPP) or correlated the medical costs with economic indicators, financing mechanisms, and policy regulations. Previous systematic reviews on costs have been limited to high-income countries while those in LMICs have only focussed on descriptive analyses of these costs.STUDY DESIGN, SIZE, DURATIONGuided by the preferred reporting items for systematic reviews and meta-analyses (PRISMA), we searched PubMed, Web of Science, Cumulative Index of Nursing and Allied Health Literature, EconLit, PsycINFO, Latin American & Caribbean Health Sciences Literature, and grey literature for studies published in all languages from LMICs between 2001 and 2020.PARTICIPANTS/MATERIALS, SETTING, METHODSThe primary outcome of interest was direct medical costs paid by patients for one ART cycle. To gauge ART affordability, direct medical costs were correlated with the GDP per capita or average income of respective countries. ART regulations and public financing mechanisms were analyzed to provide information on the healthcare contexts in the countries. The quality of included studies was assessed using the Integrated Quality Criteria for Review of Multiple Study designs.MAIN RESULTS AND THE ROLE OF CHANCEOf the 4062 studies identified, 26 studies from 17 countries met the inclusion criteria. There were wide disparities across countries in the direct medical costs paid by patients for ART ranging from USD2109 to USD18 592. Relative ART costs and GDP per capita showed a negative correlation, with the costs in Africa and South-East Asia being on average up to 200% of the GDP per capita. Lower relative costs in the Americas and the Eastern Mediterranean regions were associated with the presence of ART regulations and government financing mechanisms.LIMITATIONS, REASONS FOR CAUTIONSeveral included studies were not primarily designed to examine the cost of ART and thus lacked comprehensive details of the costs. However, a sensitivity analysis showed that exclusion of studies with below the minimum quality score did not change the conclusions on the outcome of interest.WIDER IMPLICATIONS OF THE FINDINGSGovernments in LMICs should devise appropriate ART regulatory policies and implement effective mechanisms for public financing of fertility care to improve equity in access. The findings of this review should inform advocacy for ART regulatory frameworks in LMICs and the integration of infertility treatment as an essential service under universal health coverage.STUDY FUNDING/COMPETING INTEREST(S)This work received funding from the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization (WHO). The authors declare no competing interests.TRIAL REGISTRATION NUMBERThis review is registered with PROSPERO, CRD42020199312.

Background: Assisted reproductive techniques services are often not accessible to the majority of infertile couples in Low and Middle Income Countries (LMIC) due to high costs. Lowering IVF laboratory costs is a crucial step to make IVF affordable for a larger part of the world population. We developed a simplified culture system (SCS) which has proven to be effective, and the next step is to prove its safety.Methods: Preterm birth (PTB) and low birthweight (LBW) of 176 singletons born after using the SCS, 105 after fresh embryo transfer (fresh ET), and 71 after frozen embryo transfer (frozen ET) were compared with all IVF/ICSI singletons born in Belgium between 2013 and 2018. When comparing our 105 SCS babies born after fresh ET with all Belgian babies born after conventional IVF only, we also adjusted for 7 risk factors known to influence perinatal outcome, namelythe mother's age, day of transfer, pituitary inhibition protocol, rank of cycles, number of oocytes retrieved, number of embryos transferred, and gender of the baby.Findings: Before adjustment, we found a significantly higher PTB (10.2% vs. 3.8%, OR 2.852, 95% CI [1.042-7.803], p-value 0.0413) and LBW (9.8% vs. 2.9%, OR 3.692, 95% CI [1.163-11.721], p-value 0.0267) in the conventional IVF group versus SCS after fresh ET. After adjusting for seven risk parameters, these differences remained significant (PTB: OR 2.627, 95% CI [1.013-6.816], p-value 0.0471) and LBW: OR 3.267, 95% CI [1.118-9.549], p-value 0.0305). PTB and LBW between both groups was not significantly different for singletons born after frozen ET. Interpretation: Taking into account the small series, PTB and LBW rates in SCS singletons in FRET cycles are very reassuring and significantly lower compared to babies born after conventional IVF in Belgium. Being aware of its effectiveness, our results offer a good perspective for SCS to become an important tool to implement low-cost IVF in LMIC. We want to thank Gerhard Boshoff who created the figures for this paper

Objectives: The objectives of the study were to analyze the prevalence of coronavirus disease (COVID) real-time polymerase chain reaction (RT-PCR) positivity among asymptomatic patients undergoing infertility treatment. Materials and Methods: This was an observational study done in five centers in five different cities in India, analyzing the prevalence of COVID RT-PCR-positive rates among asymptomatic patients willing to undergo infertility treatment. All patients underwent triage and COVID RT-PCR testing as per the national guidelines. Patients tested positive for COVID RT-PCR were advised to discontinue treatment. Results: The overall prevalence of COVID RT-PCR positivity in low-risk patients undergoing infertility treatment was found to be low. The incidence of COVID RT-PCR positivity in staff and doctors providing infertility care and not dealing directly with COVID-positive patients was observed to be 10.7%. Conclusion: The overall prevalence of the virus in asymptomatic people is low and elective procedure like assisted reproduction technology can be carried out with all precautions and sanitization protocols in place.

Background. Fertility preservation (FP) prior to gonadotoxic cancer treatment is underutilized in the United States (US) due to limited access to care. Objective. We aimed to determine the utilization of a regional FP program in an underserved region in the Southeast US. Methods. We performed an institutional review board-approved retrospective cohort study of patients enrolled in the FP program at an academic tertiary medical center from 2014 to 2018. Results. Sixty-nine reproductive age patients were enrolled in the FP program, including 29 men and 40 women between 20 and 49 years of age. Cancer diagnoses among the enrolled patients included hematologic (n = 34), breast (n = 14), testicular (n = 11), reproductive tract (n = 7), and gastrointestinal (n = 3) malignancies. Patients with reproductive tract malignancies were found to have approximately 9.7 times greater odds of proceeding with FP than patients with hematologic malignancies (P Conclusion. Utilization of a regional FP program should be considered to increase access to care to this critical resource for patients desiring future family building. Patients with hematologic malignancy may face unique barriers to FP.

Objective To observe the effects of practice type, location, and mandated insurance coverage on infertility physician online reviews by patients. Design Retrospective cohort study. Setting Not applicable. Patient(s) Patient online reviews of fertility specialists from 2016 to 2019. Interventions(s) None. Main Outcome Measure(s) The analysis consisted of the average rating out of 5 for each physician published on Vitals, RateMD, and Healthgrades. Result(s) Data were collected on 1,097 specialists. Physicians practicing in states with versus without mandated insurance coverage received an average rating of 4.093 versus 4.076, respectively. The average rating was 3.964 for physicians affiliated with a university or hospital versus 4.128 for those working in a private practice. Significant differences were found in physician ratings from the four regions. It was revealed that physicians who practiced in the South (n = 354) received significantly higher mean average ratings than those in the Northeast (n = 327) and Midwest (n = 175). Physicians practicing in the West (n = 241) received significantly higher ratings than those in the Midwest (n = 175). Conclusion(s) The average online patient rating of infertility specialists was found to be significantly higher for physicians working in a private practice compared with those affiliated with a university or hospital system. No significant difference was found between the average rating in states with versus without mandated insurance coverage for infertility treatment. We propose that qualities other than patient financial responsibility are implicated in the factors used to rate physicians., Highlights 1. The average online patient rating of infertility specialists was found to be significantly higher for physicians working in a private practice than for those affiliated with a university or hospital system. 2. No significant difference was found between the average rating in states with mandated insurance coverage for fertility treatment and that in states without mandated insurance coverage. 3. The average online patient ratings of infertility specialists were found to be significantly higher for physicians working in the South and West.

This commentary outlines the importance of utilizing assisted reproductive technology (ART) as an indicator of access to infertility care and provides a standard way of reporting utilization to facilitate international comparisons. Factors that influence ART utilization as well as underlying inequalities and inequities in access to care are discussed. The relevance of a marker that can inform and evaluate policy initiatives, monitor progress and document change is emphasized.

Context: The patient-centered infertility care (PCIC) approach emphasizes the patient's role in choosing the most appropriate clinical approach in infertility care. The concept can improve the patient satisfaction with care performed as well as the efficacy of the treatment. In addition, this concept can also lead to improve collaboration between patient and care provider, ultimately supporting a more cost-effective health-care scheme. Aims: This study was developed in order to determine patients' experience in their PCIC. Settings and Design: This is a descriptive study. We conducted the study in two fertility care clinics, Clinic A and Clinic B. Subjects and Methods: The Patient-Centeredness Questionnaire-Infertility (PCQ-I) was used, consisting of 7 essential themes. The questionnaire was completed by consenting patients in two infertility clinics. Statistical Analysis Used: The questionnaire was analyzed using the Statistical Package for the Social Sciences 21 version statistical software. Results: Eighty-eight Clinic A patients who completed the questionnaire responded that the best element of their treatment received was communication (correlation with global score [CGS]: 0.747), whereas the least acceptable aspect was the low accessibility (CGS: 0.211). A total of 20 Clinic B patients responded that the best element of their treatment received was respect for the patient's value (CGS: 0.866), whereas the least acceptable aspect was also the low level of accessibility (CGS: 0.193). Conclusions: The PCQ-I can be used to evaluate patients' experience during treatment and may help the health-care provider to improve their performance.

Current knowledge about infertility and access to infertility treatment among Aboriginal and Torres Strait Islander peoples is extremely limited. We conducted an online survey of Medical Directors of registered ART providers in Australia (n = 59) to obtain preliminary information on this topic. Six (10%) Directors responded; only two reported routinely collecting the Aboriginal and Torres Strait Islander status of clients. While the low response rate prevents generalising the findings, the poor engagement may indicate gaps in awareness of fertility issues for this group. This warrants further investigation, to understand whether Aboriginal and Torres Strait Islander people are appropriately accessing infertility care.

Introduction: Thyroid dysfunction is associated with increased risk of infertility. Serum thyroid stimulating hormone (TSH) screening in all women seeking infertility care is recommended and hypothyroid infertile women should be treated with thyroxine until the preconception serum TSH level is

Introduction: infertility is regarded as an upsetting and difficult life experience for some women with elevated levels of anxiety & depression. Laparoscopy is the gold standard in diagnosing various aspects of female subfertility as well as treatment of some of them at the same time.Secondary level infertility care centre includes all those can manage every aspects of problems of infertily except IVF-ET and other advance aspects of management. Objective: To find out the role of laparoscopy in the management of infertile women in a secondary level infertility care centre. Study Design: Prospective cross sectional study. Setting: Fertility care centre, Department of Obst. &Gynaecology Dhaka Medical College Hospital from January 2018 to June 2018. Methods: During the study period 328 infertile women attended infertility outdoor. .Among them 48 were admitted for diagnostic laparoscopy. Results: Out of forty eight women 26 (54%) had primary infertility, 22 (46%) had secondary infertility.The findings were PCOS in 22% of cases, endometriosis in 14%, PID in 15% cases,unexplained in 20%, fibroid uterus in 6% cases congenital anomaly of uterus in 1% and others in 22% . Conclusion: Laparoscopy is the gold standard in evaluating infertile women.Some women would have a correctable problem found at laparoscopy that would not be discovered with any other fertility screening tests like endometriosis. J Shaheed Suhrawardy Med Coll, June 2019, Vol.11(1); 9-12

Infertility represents a very peculiar area of medicine. Contrary to other areas, where signs and symptoms lead to a diagnosis, which in turn leads to a specific treatment, in reproduction the lack of signs and symptoms for more than 12 months suggests the diagnosis of ‘unexplained subfertility’, and if this condition has lasted for some years, couples qualify for IVF. Diagnosis and treatments can extend over long periods of time (even years) and the accuracy of the diagnostic armamentarium is not optimal. Uncertainty about diagnosis and the need for significant perseverance is demanding on both couples and physicians, and actually constitute a very favourable situation for overdiagnosis (‘unexplained subfertility’) and overtreatment (IVF) on one hand, and, on the other, it may also affect compliance with treatments. To improve our capacity to properly handle this challenging situation, increased attention should be given to the duration of pregnancy seeking. Initiating treatments earlier in older women is unwise because this population has a lower fecundity and, therefore, duration of pregnancy seeking is even more important to achieve a reliable diagnosis of infertility. Moreover, if the infertility work-up is unremarkable, duration of pregnancy seeking should be extended up to more than 2 years prior to making a diagnosis of unexplained infertility regardless of age. An adequate period of pregnancy seeking is also required for couples who are diagnosed with conditions that can interfere with fertility to avoid overdiagnosis and overtreatment. Indeed, most causes of infertility will reduce but not impair natural conception. Within this sometimes long-term management, physicians should also pay attention to detrimental life habits in order to optimize the chances of both natural and assisted reproduction technology -mediated pregnancy. Even if interventional studies are not conclusive, it is advisable to address the problems of obesity and smoking. Focussing on frequency of sexual intercourse may be also beneficial for natural conception. Finally, there is the need for improving our capacity to handle compliance. Providing information on the importance of persevering at the start of treatment, promoting shared decision-making and tackling patient, clinic and treatment causes of drop-out can all improve the overall chances of parenthood. Thus, we plead for a wiser and more pragmatic approach to infertility, paying more attention to these neglected, but in our opinion essential, aspects of infertility care.

PURPOSE: How can elective egg freezing (EEF) be made patient centered? This study asked women to reflect on their experiences of EEF, which included their insights and recommendations on the optimal delivery of patient-centered care. METHODS: In this binational, qualitative study, 150 women (114 in the USA, 36 in Israel) who had completed at least one cycle of EEF were recruited from four American IVF clinics (two academic, two private) and three in Israel (one academic, two private) over a two-year period (June 2014–August 2016). Women who volunteered for the study were interviewed by two medical anthropologists. Interviews were audio recorded, transcribed, and entered into a qualitative data management program (Dedoose) for analysis. RESULTS: The majority (85%) of women were without partners at the time of EEF, and thus were undertaking EEF alone in mostly couples-oriented IVF clinics. Following the conceptual framework known as “patient-centered infertility care,” we identified two broad categories and eleven specific dimensions of patient-centered EEF care, including (1) system factors: information, competence of clinic and staff, coordination and integration, accessibility, physical comfort, continuity and transition, and cost and (2) human factors: attitude and relationship with staff, communication, patient involvement and privacy, and emotional support. Cost was a unique factor of importance in both countries, despite their different healthcare delivery systems. CONCLUSIONS: Single women who are pursuing EEF alone in the mostly couples-oriented world of IVF have distinct and multifaceted needs. IVF clinics should strive to make best practices for patient-centered EEF care a high priority.

Study question What are the available preconception care policies, guidelines, recommendations and services as well as infertility care in South America ? Summary answer Preconception recommendations offered by both governament and medical societies in South America were fragmented and inconsistent and public fertility care is available in seven countries. What is known already Promoting preconception health can potentially improve women’s health and pregnancy outcomes. Evidence-based interventions exist to reduce many maternal behaviors and chronic conditions that are associated with adverse pregnancy outcomes such as tobacco use, alcohol use, inadequate folic acid intake, obesity, hypertension, and diabetes. Paternal factors are also influence pregnancy outcomes but male preconcepction health has received little attention so far and he focus remains on women. Study design, size, duration Cross-sectional evaluation including ann electronic search and investigation of preconception policy, guidelines, recommendations and services available to healthcare professionals and the general public in south America (N = 11 countries): Argentina, Bolívia, Brasil, Chile, Colômbia, Ecuador, , Paraguay, Peru, Suriname, Uruguay and Venezuela) that took place in June 2020. No ethical approval was obtained as we used only public avalialble online information. Participants/materials, setting, methods Eleven South American countries) were included Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, , Paraguay, Peru, Suriname, Uruguay and Venezuela.we searched Google using advanced search setup for each country with the following words: Preconception care; Pre-pregnancy care; Before pregnancy; Conception; Pregnancy planning; Preconceptual and variations and Policy; Guidelines, Recommendations and services. Data from the Latin American Registry (REDLARA, 2017) and the Latin American Federation of Societies of Obstetrics and Gynecology (FLASOG) was also obtained . Main results and the role of chance Government preconcepction care recommendations were available in 10 countries and 11 had family planning guidelines. Seven countries offered either public clinics or financial aid for infertile couples. According to REDLARA 2017 report there are 122 registered centers in South America but the region host much more. The Brazilian registry shows 154 IVF clinics in 2018. Although most countries offered guidance on major issues including folic acid supplementation (n = 10), nutrition (n = 10), Vaccination (n = 11), alcohol consumption (n = 11), smoking (n = 10), relevant health topics such physical activity (n = 7) and obesity (n = 7) were left out in 58,3% of the countries. Medical societies provided guidelines on preconcpection care in 7 countries and for other health issues: folic acid supplementation (n = 5), nutrition (n = 5), Vaccination (n = 6), alcohol consumption (n = 4), smoking (n = 4), physical activity (n = 4)and obesity (n = 2). When male preconception care was considered, only two countries have public guidelines whereas no medical society provided specific recommendations for men. Sexually transmitted diseases (STD) was another topic of interest for both public (n = 10) and medical societies (n = 4). STD guidelines were heterogenous and focused more on treatment rather than prevention. FLASOG however displayed guidelines for peconception care and STD prevention. Limitations, reasons for caution The search was performed only in Google as it is the most opular search engine. We did not include other search pages asuch as Yahoo and limited our search to the first 3 pages for each search term as people rarely examine more thatn the first there pages. Wider implications of the findings: Current reccomendations are heterogeneous, fragmented and inconsitent and there is a lack of interest on male reproductive health y. Public fertility care is only available in 7 countries. Collaborative research among countries is necessary so as to develop evidence-based guidelines for preconcepction and fertility care for both men and women. Trial registration number not-applicable

Study question What is the burden of early infertility care drop-out in the context of full reimbursement of infertility care and are medical practices associated with drop-out? Summary answer Medical practices seem associated with early infertility care drop-out whose burden remains high despite the equality of care policy in France What is known already More than half of couples drop out of their infertility treatment before pregnancy. Direct costs of infertility care are widely cited as the major barrier to continuation of care. In France, infertility treatments are fully reimbursed. Data from US IVF centres have shown a high estimated drop-out from the beginning and at each step of infertility treatment. Some studies have suggested a difference in medical practices during infertility care between couples who have dropped out and couples who have continued care Study design, size, duration Cohort study of all women aged 18–49 years who started infertility treatment between January–August 2016 in mainland France with a private practitioner and who had not been successfully treated at a 24-month follow-up. Participants/materials, setting, methods The cohort was based on the French national health insurance and hospital databases that exhaustively record reimbursed healthcare. Infertility treatment included ovarian induction by gonadotropin and clomifene. Outcome was infertility care drop-out within 3 months after starting treatment. Stratified analyses were performed based on the first treatment prescribed, with three categories: clomifene prescribed by a general practitioner, clomifene by a gynaecologist or gonadotropin by a gynaecologist Main results and the role of chance Among women unsuccessfully treated by ovarian induction, 31.1% dropped out of infertility care within 3 months. Women who started treatment with a general practitioner were more frequently socially disadvantaged (40.6%), less closely monitored (ultrasound and hormonal tests had not been done in 53.6% and 64.8%, respectively) and dropped out more frequently (46.8%). Where the prescriber of treatment was a gynaecologist, older age (35–39 and 40–43 years) was associated with higher probability of early drop-out with OR 1.5 (95% CI 1.3–1.7) and 2.2 (95% CI 1.9–2.5) for gonadotropins and 1.2 (95% CI 1.1–1.3) and 1.9 (95% CI 1.7–2.2) for clomifene. Disadvantaged social status was associated with higher early infertility care drop-out, whereas good monitoring was associated with a lower probability of early drop-out in all three categories of treatments and prescribers Limitations, reasons for caution These medical and administrative data did not allow us to explore medical practices in greater depth, notably the doctor-patient relationship Wider implications of the findings: This is the first estimation of early infertility care drop-out in a general population where treatment is fully reimbursed, exploring the implication of medical practices in early drop-out. Better access to good medical practices is needed for less socially advantaged people, beyond the current equality of care policy in France. Trial registration number N/A

ObjectiveThe current study aims to define patient-centred infertility care (PCIC) from the perspective of Arab women with infertility.DesignSemistructured in-depth telephone interviews.SettingHospitals providing infertility care, Jeddah, Saudi Arabia.ParticipantsArab women who received infertility treatment during the 6 months preceding the interview at any hospital in Jeddah, Saudi Arabia. Interviews were conducted with Arab women experiencing infertility from January 2017 to December 2018. A purposive sample of 14 women were included in the final analysis with maximum variation.ResultsParticipants highlighted nine important PCIC dimensions. Of these, four were agreed on by all participants: accessibility, minimising cost, information and education, and staff attitudes and communication. The remaining five dimensions were staff competence, physical comfort, privacy, psychological and emotional support, and continuity and coordination of care. The concept of PCIC was related to three major contributors: participants’ demographics, patient experience with infertility care and health-seeking behaviour.ConclusionsThe current study provided nine PCIC dimensions and items, which can guide efforts to improve the quality of infertility care in Arab countries in two ways: first, by raising infertility care providers’ awareness of their patients’ needs, and second, by developing a validated tool based on the dimensions for measuring PCIC from Arab patients’ perspective. Clear differences between the Arab and the European PCIC model were found. Our findings concluded that women continued to exhibit basic unmet needs.

UIDB/00183/2020 UIDP/00183/2020 SFRH/BPD/115073/2016 PTDC/FER-FIL/28278/2017 Background: Misunderstandings in medical interactions can compromise the quality of communication and affect self-management, especially in complex interactions like those in the assisted reproductive technology (ART) field. This study aimed to detect and describe misunderstandings in ART triadic visits. We compared first and follow-up visits for frequency, type, speakers, and topics leading to misunderstandings. Methods: We purposively sampled 20 triadic interactions from a corpus of 85 visits. We used a previously developed coding scheme to detect different types of misunderstandings (i.e., with strong, acceptable, and weak evidence). We analyzed also the different topics leading to strong misunderstandings (direct expressions of lack of understanding, pragmatic alternative understandings, semantic alternative understandings) to provide insights about the contents of the consultation that may need particular attention and care. Findings: We detected an overall number of 1078 misunderstandings in the 20 selected visits. First visits contained almost two-third of the misunderstandings (n = 680, 63%). First visits were particularly rich in misunderstandings with acceptable evidence (e.g., clarifications and checks for understanding), compared to follow-up visits. In first visits, doctors’ turns more frequently than couples’ turns contained misunderstandings, while in follow-up visits it was the other way around. Looking at the couple, the majority of the misunderstandings were expressed by the woman (n = 241, 22%) rather than by the man (n = 194, 18%). However, when weighting for their number of turns, 9% of the men’s turns included an expression of misunderstanding, compared to the 7% of the women’s turns. Finally, more than half of the misunderstandings with strong evidence were about history-taking and treatment-related topics, and while the history-taking ones were particularly frequent in first visits the treatment-related ones were more present in follow-up visits. Discussion: Findings indicate that first visits may deserve particular attention to avoid misunderstandings, as they are the moment where a shared understanding can be harder to reach. In particular, misunderstandings happening in first visits seem mostly related to physicians having to reconstruct the clinical history of patients, while those in the follow-up visits seem to reflect residual and unsolved doubts from the couple, especially concerning treatments. publishersversion published

Introduction : Couples aiming to become parents turn to medically assisted procreation (MAP) with increasing frequency. This procedure has been the subject of variety of studies, with a focus on the obstetrical point of view. However, the psychological aspect has been underdeveloped in present-day research works. Method : The goal of the survey was to study the care and treatment of women who relied on MAP for their pregnancy. Collaborating with the MAP department of a university hospital of the Auvergne Rhône Alpes region, and using social networks, a qualitative descriptive and interpretative study has been performed. One couple and seven women were surveyed through semi-structured interviews.Results : The handling of the pregnancy has been met with satisfaction for most, although some differences of opinion on certain matters have been revealed, without it being confined to the pregnancy period. Discussion : The already significant emotional baggage associated with childbearing is coming up frequently during pregnancy, and it has an impact on multiple levels, which has been highlighted in this study.Conclusion : Communication, crucial during such events, is not always an easy task. The study has underlined that even if some people wish to have a different monitoring during pregnancy, other might want this kind of support post-partum.; Introduction : Les couples désireux de devenir parents ont de plus en plus recours à l’AMP. Ce procédé a fait l’objet de plusieurs études mais surtout sur le versant obstétrical. Cependant le versant psychologique est peu développé dans les travaux de recherche actuels. Méthode : L’objectif de l’enquête était d’étudier la prise en charge des femmes ayant eu recours à l’AMP pour leur grossesse, par les professionnels de santé. En collaboration avec le service d’AMP d’un CHU de la région Auvergne Rhône Alpes, ainsi que via les réseaux sociaux, une étude qualitative descriptive et interprétative a été réalisée. Un couple et sept femmes ont été interrogés par le biais d’entretiens semi-directifs. Résultats : La prise en charge de la grossesse a pour la majorité été bien vécue cependant des divergences d’opinion sur certains points apparaissent, ne se limitant pas seulement à cette période-là. Discussion : La charge émotionnelle déjà importante pendant le parcours ressort très souvent pendant la grossesse et a un impact à différents niveaux, qui a été mise en avant dans cette étude. Conclusion : La communication, primordiale dans des événements pareils, n’est pas toujours facile. L’étude a mis en avant que même si certaines souhaitent avoir un suivi différent pendant la grossesse, d’autres veulent plutôt cet accompagnement là en post-partum.

The COVID-19 pandemic has forced many changes to how we interact in society, requiring that we protect ourselves and others from an invisible, airborne enemy called the SARS-CoV-2 virus. Until a vaccine is discovered and reaches high levels of distribution, everyone must continue to be diligent to limit viral spread. The practice of assisted reproduction during this pandemic presents unique challenges in addition to the risks that have been identified for general clinical care. The established good tissue practices employed in laboratories are not designed to protect gametes and embryos from an airborne virus, particularly one that may be shed by an asymptomatic staff member. Armed with theoretical risks, but lacking direct evidence, assisted reproduction teams must examine every aspect of their practice, identify areas at risk for exposure to the SARS-Cov-2 virus and develop a mitigation plan. Several professional fertility societies have created guidelines for best practices in patient care during the COVID-19 pandemic. As we learn more about SARS-CoV-2 updates have been issued to help adapt infection control and prevention protocols. This review discusses what is currently known about SARS-CoV-2 infection risks in assisted reproductive centers and recommends implementation of specific mitigation strategies., Capsule: SARS-CoV-2 infection risks and mitigation strategies for assisted reproductive centers are reviewed. Implementation of safety precautions are suggested based on current literature and society guidelines.

Introduction: We aimed to describe infertility insurance coverage provided to male and female fellows working at institutions that offer advanced infertility training. Methods: Faculty and fellows working within U.S. and Canadian Andrology or Reproductive Endocrinology and Infertility (REI) programs were contacted and asked for a copy of their institutional health insurance summary of benefits. Documents were assessed for coverage of diagnosis and treatment, shared costs, and maximum lifetime coverage for infertility care. Results: Insurance policies from 24 institutions were reviewed; 16 of 24 (66%) institutions covered costs related to the diagnosis of infertility. Six institutions (25%) offered coverage for diagnosis but not treatment. There were 15 (62.5%) institutions that offered some amount of coverage for the treatment of infertility, and the average lifetime maximum was $16 100. Only six of 24 (25%) plans explicitly described a covered male-specific treatment, which included sperm extraction (12.5%), varicocele repair (4.2%), and sperm cryopreservation (8.3%). Conclusions: For physician trainees, infertility insurance coverage is not universal, policies are not transparent, and treatment for male factor infertility is often omitted. With high costs of infertility treatment, variable insurance coverage, and debt and time constraints, residents and fellows are a particularly vulnerable population that may experience significant financial toxicity when faced with infertility.

PURPOSE: (1) To test the hypothesis that under-represented minority women, including Hispanic/Latina and African American or Black women, will be more likely to report greater socioeconomic and cultural barriers to infertility care compared with white women. (2) To identify gaps in knowledge that can guide future educational interventions. METHODS: A cross-sectional survey was completed by 242 women, ages 18–44, at five gynecology clinics in the greater Boston, Massachusetts area from February 27, 2018, to February 25, 2019. RESULTS: Of the respondents, 61.4% identified as Hispanic/Latina, 24.5% as white, and 6.6% as Black or African American. Cost was the most commonly reported barrier to care (62.8%) regardless of race/ethnicity or insurance status. Only 8.9% of participants were aware of personal insurance coverage for infertility treatment. Compared with white patients, Hispanic/Latina patients were less likely to know if their own insurance covered infertility treatment: 14.3% vs 6.8%; aRR 0.36 (95% CI 0.17–0.74), after adjusting for a personal history of infertility. CONCLUSION: Cost was the most commonly reported barrier to care. Most women were unaware of their insurance coverage despite the state insurance mandate to cover infertility treatment in Massachusetts. Education and outreach will be instrumental in helping address disparities in access to care.

Background Infertility has recently become a salient but neglected global issue. Policies to address the sexual and reproductive health and rights (SRHR) are vital, especially in lower middle and middle-income countries (LMICs). Hence, the aim of this study was to compare the national infertility policies in the selected countries (LMICs comparing with high-income) to determine gaps or to confirm desirable policies in the given health systems. Methods This study has executed a comparative policy analysis of infertility services using the universal health coverage framework (financial protection, population coverage, and service features) in three scopes (prevention, treatment, and supportive care). Seven countries that had infertility programs in their health sectors were selected. Results The results showed that financial protection was good in high and middle-income countries, but in a lower middle income, and in one high-income country was poor. The findings also showed that health systems in the same countries had no infertility services for men. Preventive and supportive care services were neglected in LMICs by governments. Conclusion The findings indicate that income is not the only factor that fulfills universal health coverage for infertility care services. Perhaps to achieve equity in infertility care services, it should be seen as a universal human right to accomplish the right to have a child and to have a life with physical and mental health for all men and women.

Since October 2001, more than 2.7 million men and women of the armed forces have been deployed to Iraq, Afghanistan, or in support of the “Global War on Terrorism.” Like previous wars, our nation will feel the after-effects of those deployments for a generation to come, as the wounds of war do not just affect the veteran, but impact their family and friends once they return to the home front. But unlike previous wars, less than 1% of our population serves their country in an all-volunteer military. This small percentage of Americans who volunteer to serve us and protect our freedoms (no matter what you might think about the politics surrounding wars) is increasingly removed from the rest of the population who choose other careers and options. Therefore, most of us are uneducated and unconnected to the often isolating experiences and frustrations of our veterans when they return to the home front and try to retake the stage of their former lives. In this discussion, we share the compelling stories of military members and veterans who struggle with infertility. We describe the need for policy and expansion of services for infertility care in the Department of Defense and Veterans Health Administration, and the challenges and opportunities that exist.

Infertility prevalence and care needs among male and female Veterans are understudied topics. The Veterans Health Administration (VHA) medical benefits package covers full infertility evaluation and many infertility treatments for Veterans but not, by law, for their spouses. In vitro fertilization (IVF) is also specifically excluded from this medical benefits package by regulation. Congress passed a law in 2016 that allowed VHA to provide IVF to Veterans and their legal spouses, and broader infertility benefits to the legal spouse, if the Veteran has a service-connected condition associated with his or her infertility, with some limitations. As the Veteran population becomes increasingly female, research efforts in reproductive health, including infertility, are expanding and evolving. This includes a nationwide study currently underway examining infertility among male and female Veterans and associations with military-related trauma, such as injury, posttraumatic stress disorder, military sexual trauma, and toxin exposure. In this review, we describe the state of the science and policy on infertility care in the VHA along with challenges and opportunities that exist within the VHA system.