The impact of a reminder email on the return to care behavior of infertility patients after a first office visit: A quality improvement project.

Research question: Prior research has determined that up to half of infertility patients attend one visit with an infertility specialist but do not return for a diagnostic workup or treatment. As part of a quality-of-care improvement project, patients who had not returned after one visit with an infertility specialist received an email which asked why they had not returned. The return to care behavior was then compared to a period of time when the email was not sent out, to answer the question as to whether or not the email had a significant impact on behavior. Design: From July 2017 to March 2018, 301 eligible patients who attended one visit but did not return to care received an email; 657 subsequent patients from April to December 2018 did not receive one. The email asked questions about that visit, offered support, contact information for the employee sending the email and why they had not returned. Results: All patients were followed for 11 months after their initial visit. Forty-one percent of the email group returned to care, compared to 32% who did not (P < 0.0014). For those who gave a reason why they hadn't returned, 32% of the respondents conceived on their own, 3% transferred to another infertility center, 31% were taking a break, 3% were unhappy with their care, and 31% made a return to care appointment. Thus, the email was associated with a significant increase in return to care when compared to women who did not receive an email. The most common reason why patients did not return was spontaneous conception closely followed by taking a break. Conclusions: A compassionate email sent after one visit may increase return to care behavior.

Impact of empathic physician contact on patient anxiety and distress during the waiting period after embryo transfer: a randomized controlled trial.

RESEARCH QUESTION: Can an empathic physician phone call in the interval between embryo transfer and first serum human chorionic gonadotrophin measurement decrease anxiety and distress amongst patients undergoing IVF? DESIGN: This was a randomized controlled trial at a single academically-affiliated fertility centre including patients aged 18-43 undergoing their first embryo transfer with autologous fresh or euploid cryopreserved embryos following preimplantation genetic testing for aneuploidies (frozen embryo transfer, FET/PGT-A). After embryo transfer, participants were randomized to a 5-minute scripted phone call (intervention) from a single physician 3-4 days after embryo transfer or to routine care. The primary and secondary outcomes included were change in State-Trait Anxiety Inventory (STAI) and Hospital Anxiety and Depression Scale (HADS) scores from the start of IVF stimulation to 8-9 days after embryo transfer, respectively. RESULTS: A total of 231 participants (164 fresh, 67 FET/PGT-A) were randomized to intervention (n = 116) or routine care (n = 115). While mean STAI and HADS scores increased in both groups, the intervention group experienced lower mean increases than the routine care group for both the STAI (3.3 [0.97] versus 7.8 [1.10], respectively; P = 0.002) and the HADS (0.3 [0.44] versus 2.4 [0.53], respectively; P = 0.003). Most participants in the intervention group found the call helpful (91.4%) and reported that it decreased distress and anxiety (81%). CONCLUSIONS: A brief empathic phone call from a physician during the waiting period resulted in significantly lower self-reported levels of patient anxiety and distress. As the intervention in this study averaged 5 min, implementing this in clinical practice would not be onerous and may ease the distress associated with the waiting period.

Embryo donation: Survey of in-vitro fertilization (IVF) patients and randomized trial of complimentary counseling.

DESIGN: This study surveyed patients with stored frozen embryos and developed and tested an intervention through a randomized trial to support subjects to consider embryo disposition options (EDOs), especially donation for family building. METHODS: Based on a review of literature on EDOs, the authors developed and mailed a 2-page anonymous survey to 1,053 patients in Massachusetts (USA) to elicit their feelings about their stored embryos. Target patients had embryos cryopreserved for ≥1 year and had not indicated an EDO. Survey respondents were next randomized between usual care (control arm) or an offer of complimentary counseling and educational support regarding EDOs. These counseling sessions were conducted by a licensed mental health professional specializing in infertility treatment. RESULTS: Despite telephone reminders, only 21.3% of patients responded, likely reflecting most patients' reluctance to address EDOs. Respondents endorsed an average of 2 of the 5 EDOs, with the following percentages supporting each option: store for future attempts (82%), continue storage (79%), donate to research (29%), discard (14%), and donate for family building (13%). When asked their opinions towards embryo donation to another couple, 78% of patients agreed that donation is a way to help another couple, 48% would consider embryo donation to another family if they had a better understanding of the process, and 38% would be willing to consider donation if they were not going to use the embryos themselves, but 73% expressed discomfort with donation. In the randomized trial, 7.8% of intervention subjects (n = 8) obtained counseling sessions compared to 0.0% (none) of usual care subjects (p = 0.0069). Counseling participants valued not only discussing EDOs, but also assistance in expressing their feelings and differences with their partners. CONCLUSION: Improvement in counseling rates over the control arm suggests that free professional counseling is a small, but likely effective, step towards deciding on an EDO. ClinicalTrials.gov Identifier: NCT01883934 (Frozen embryo donation study).

Burden of care is the primary reason why insured women terminate in vitro fertilization treatment.

OBJECTIVE: To study the reason(s) why insured patients discontinue in vitro fertilization (IVF) before achieving a live birth. DESIGN: Cross-sectional study. SETTING: Private academically affiliated infertility center. PATIENT(S): A total of 893 insured women who had completed one IVF cycle but did not return for treatment for at least 1 year and who had not achieved a live birth were identified; 312 eligible women completed the survey. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Reasons for treatment termination. RESULT(S): Two-thirds of the participants (65.2%) did not seek care elsewhere and discontinued treatment. When asked why they discontinued treatment, these women indicated that further treatment was too stressful (40.2%), they could not afford out-of-pocket costs (25.1%), they had lost insurance coverage (24.6%), or they had conceived spontaneously (24.1%). Among those citing stress as a reason for discontinuing treatment (n = 80), the top sources of stress included already having given IVF their best chance (65.0%), feeling too stressed to continue (47.5%), and infertility taking too much of a toll on their relationship (36.3%). When participants were asked what could have made their experience better, the most common suggestions were evening/weekend office hours (47.4%) and easy access to a mental health professional (39.4%). Of the 34.8% of women who sought care elsewhere, the most common reason given was wanting a second opinion (55.7%). CONCLUSION(S): Psychologic burden was the most common reason why insured patients reported discontinuing IVF treatment. Stress reduction strategies are desired by patients and could affect the decision to terminate treatment.

The relationship between stress and infertility.

The relationship between stress and infertility has been debated for years. Women with infertility report elevated levels of anxiety and depression, so it is clear that infertility causes stress. What is less clear, however, is whether or not stress causes infertility. The impact of distress on treatment outcome is difficult to investigate for a number of factors, including inaccurate self-report measures and feelings of increased optimism at treatment onset. However, the most recent research has documented the efficacy of psychological interventions in lowering psychological distress as well as being associated with significant increases in pregnancy rates. A cognitive-behavioral group approach may be the most efficient way to achieve both goals. Given the distress levels reported by many infertile women, it is vital to expand the availability of these programs.

Por años ha sido debatida la relación entre estrés e infertilidad. En las mujeres con infertilidad se encuentran puntuaciones elevadas de ansiedad y depresión, por lo que está claro que la infertilidad causa estrés. Sin embargo, lo que está menos claro es si el estrés causa o no infertilidad. Por numerosos factores, como las inexactas mediciones de auto-reporte y los sentimientos de aumentado optimismo al comienzo de los tratamientos es difícil investigar el impacto del distrés en el resultado terapéutico. Ahora bien, la investigación más reciente ha documentado la eficacia de las intervenciones psicológicas en la reducción del distrés psicológico, además de asociarse con aumentos significativos en la frecuencia de embarazos. Una aproximación grupal cognitivo conductual puede ser la forma más eficiente para alcanzar ambos objetivos. Es vital expandir la disponibilidad de estos programas, dado los niveles de distrés reportados por muchas mujeres infértiles.

La relation entre le stress et l'infertilité est débattue depuis des années. Les niveaux d'anxiété et de dépression des femmes infertiles sont élevés, il est donc clair que l'infertilité provoque du stress. Ce qui est néanmoins moins clair c'est de savoir si le stress entraîne, ou pas, de l'infertilité. De nombreux facteurs rendent difficile la recherche sur l'effet de l'anxiété sur les résultats thérapeutiques, comme les auto-mesures imprécises, et les sentiments d'optimisme accru au début du traitement. Cependant, d'après les recherches les plus récentes, la prise en charge psychologique est efficace pour diminuer l'anxiété et elle s'associe aussi à des taux de grossesses significativement augmentés. C'est l'approche cognitivo-comportementale de groupe qui semble la plus efficace pour atteindre ces deux buts. Il est vital d'élargir la disponibilité de ces programmes compte tenu des niveaux d'anxiété rapportés par de nombreuses femmes infertiles.

The impact of stress on fertility treatment.

PURPOSE OF REVIEW: The goal of this review was to summarize the recent research on the relationship between stress and assisted reproductive technology treatment. RECENT FINDINGS: Women and men with infertility report high levels of distress that can impact their quality of life. There are numerous psychosocial interventions, including cognitive behavior therapy and/or self-help ones, which may decrease distress, increase patient retention and improve pregnancy rates. SUMMARY: Patient distress is an important factor to consider. Decreasing burden of care may lead to significant improvements in assisted reproductive technology outcome.

Lifestyle habits of 12,800 IVF patients: Prevalence of negative lifestyle behaviors, and impact of region and insurance coverage.

Lifestyle habits of women undergoing in vitro fertilization (IVF) treatment are largely unknown. Therefore, this prospective study aimed to determine the prevalence of negative lifestyle habits in women undergoing IVF and determine if habits are related to the region in the United States and/or by mandated insurance coverage. A total of 12,811 ART patients were surveyed in infertility clinics throughout the US. They took an online questionnaire added to the patient portal of electronic medical record eIVF, a fertility-specific electronic health record. Of the women surveyed, 17-23% of patients drank alcohol, 2-7% smoked, 62-68% drank caffeine, < 1% used recreational drugs, and 47-62% exercised during their IVF treatment. There were a few statistically significant regional differences in health habits (p < 0.001) but there were no differences in health habits between women who resided in a state with mandated insurance coverage versus those without insurance coverage. This is the first prospective assessment of lifestyle habits across regions in the USA and by insurance coverage. The study concluded that women undergoing IVF engage in behaviors which may negatively impact their cycle. Women in certain parts of the US had significantly worse habits than other regions, but the availability of mandated insurance coverage did not impact health habits.

Exploratory randomized trial on the effect of a brief psychological intervention on emotions, quality of life, discontinuation, and pregnancy rates in in vitro fertilization patients.

OBJECTIVE: To determine whether a brief self-administered cognitive coping and relaxation intervention (CCRI) would lead to decreased treatment termination in in vitro fertilization (IVF) patients compared with routine care (RC). DESIGN: Randomized, controlled, prospective study. SETTING: Private academically affiliated infertility center. PATIENT(S): One hundred sixty-six women about to begin their first IVF cycle. INTERVENTION(S): Randomization to the self-administered CCRI or RC control group and then observation for 12 months. MAIN OUTCOME MEASURE(S): Treatment discontinuation within 12 months (primary outcome), clinical pregnancy rate and psychological well-being (secondary outcomes). RESULT(S): The 12-month pregnancy rate was similar for the RC and CCRI groups (odds ratio [OR] 1.02; 95% CI, 0.53-1.98). Of the patients who were not pregnant on the first cycle, 15 of 46 (15.2%) patients assigned to RC discontinued compared with 5 of 55 (5.5%) patients assigned to the CCRI (OR 3.11; 95% CI, 0.756-12.80). The CCRI group engaged in statistically significantly more positive reappraisal coping (OR 0.275; 95% CI, 0.16, 0.39) than the RC control group (OR 0.097; 95% CI, -0.03, .23). The CCRI group had an improved Fertility Quality of Life (FertiQoL CORE: OR 4.07; 95% CI, 2.07, 6.06; FertiQoL Emotional: OR 5.95; 95% CI, 2.89, 9.00) compared with the control group (Core OR: 0.67; 95% CI, -1.55, 2.89; Emotional: OR -0.02, 95% CI, -3.36, 3.32). The CCRI group reported less global anxiety (OR 0.275; 95% CI, 0.16, 0.39) than the control group (OR 0.471; 95% CI, -2.40, 3.34). The CCRI reported positive evaluations for the intervention (e.g., ease of use, helpfulness, perceived stress reduction). CONCLUSION(S): Use of the CCRI tool led to improved psychological status but not statistically significantly more treatment cycles or a higher pregnancy rate. CLINICAL TRIAL REGISTRATION NUMBER: NCT01318291.

The impact of lifestyle behaviors on infertility treatment outcome.

PURPOSE OF REVIEW: The impact of lifestyle behaviors on fertility is poorly understood, as is the impact of specific behaviors on the advanced reproductive technologies. It is vital for healthcare professionals to understand which lifestyle behaviors can have the greatest negative impact in an effort to improve patient recommendations. The purpose of this article is to review the recent research on this topic. RECENT FINDINGS: The majority of research in this area is epidemiological; there are a few randomized controlled trials (RCTs) regarding weight loss in infertility patients, but no RCTs on other lifestyle behaviors. High or low BMI, alcohol, vigorous exercise, nicotine, and antidepressant medications may have an adverse impact on fertility. It is unclear whether dietary supplements can have a positive impact on fertility. Patients do not appear to follow recommendations for lifestyle behavior modifications during infertility treatment. SUMMARY: Healthcare professionals need to be more effective in making lifestyle behavior recommendations for infertility patients, including those receiving treatment. VIDEO ABSTRACT: http://links.lww.com/COOG/A13.

Sexual activity and function in women with and without pelvic floor disorders.

INTRODUCTION AND HYPOTHESIS: We describe differences in sexual activity and function in women with and without pelvic floor disorders (PFDs). METHODS: Heterosexual women ≥40 years of age who presented to either urogynecology or general gynecology clinics at 11 clinical sites were recruited. Women were asked if they were sexually active with a male partner. Validated questionnaires and Pelvic Organ Prolapse Quantification (POP-Q) examinations assessed urinary incontinence (UI), fecal incontinence (FI), and/or pelvic organ prolapse (POP). Sexual activity and function was measured by the Female Sexual Function Index (FSFI). Student's t test was used to assess continuous variables; categorical variables were assessed with Fisher's exact test and logistic regression. Univariate and multivariate analyses were used to assess the impact of pelvic floor disorders (PFDs) on FSFI total and domain scores. RESULTS: Five hundred and five women met eligibility requirements and gave consent for participation. Women with and without PFDs did not differ in race, body mass index (BMI), comorbid medical conditions, or hormone use. Women with PFDs were slightly older than women without PFDs (55.6 + 10.8 vs. 51.6 + 8.3 years, P <0.001); all analyses were controlled for age. Women with PFDs were as likely to be sexually active as women without PFDs (61.6 vs. 75.5 %, P = 0.09). There was no difference in total FSFI scores between cohorts (23.2 + 8.5 vs. 24.4 + 9.2, P = 0.23) or FSFI domain scores (all P = NS). CONCLUSION: Rates of sexual activity and function are not different between women with and without PFDs.

Lifestyle behaviors in women undergoing in vitro fertilization: a prospective study.

OBJECTIVE: To determine the lifestyle behaviors of women before and during an IVF cycle. DESIGN: Prospective survey. SETTING: Private academically affiliated infertility center. PATIENT(S): One hundred eighteen women, ages 18-44, scheduled to undergo an assisted reproductive technology (ART) cycle using their own eggs. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Lifestyle history and daily habit survey. RESULT(S): In the month before their IVF cycle, 92% exercised, 3% smoked, 73% drank alcohol, 76% drank caffeinated beverages, 14% took herbs, and 30% underwent acupuncture. During their ART cycle, 100% exercised, 2% smoked, 49% drank alcohol, 77% drank caffeine, 12% took herbs, and 47% underwent acupuncture. CONCLUSION(S): This is the first prospective assessment of numerous lifestyle habits during an ART cycle. A number of surprising observations were made. Despite physician recommendation against it, some ART patients took herbs while cycling. Patients continue to exercise regularly and drink caffeine daily, and almost half continued to drink alcohol. Lifestyle behavior counseling should be considered for patients pursuing ART. CLINICAL TRIAL REGISTRATION NUMBER: NCT01119391.

Impact of a group mind/body intervention on pregnancy rates in IVF patients.

OBJECTIVE: To determine if women who were randomized to a mind/body program before starting their first IVF cycle would have higher pregnancy rates than control subjects. DESIGN: Randomized, controlled, prospective study. SETTING: Private academically affiliated infertility center. PATIENT(S): A total of 143 women aged≤40 years who were about to begin their first IVF cycle. INTERVENTION(S): Subjects were randomized to a ten-session mind/body program (MB) or a control group and followed for two IVF cycles. MAIN OUTCOME MEASURE(S): Clinical pregnancy rate. RESULT(S): Only 9% of the MB participants had attended at least one-half of their sessions at cycle 1 start. Pregnancy rates for cycle 1 were 43% for all subjects; 76% of the MB subjects had attended at least one-half of their sessions at cycle 2 start. Pregnancy rates for cycle 2 were 52% for MB and 20% for control. CONCLUSION(S): MB participation was associated with increased pregnancy rates for cycle 2, prior to which most subjects had attended at least half of their sessions.

Dyspareunia associated with paraurethral banding in the transobturator sling.

OBJECTIVE: We sought to compare the development of paraurethral banding and subsequent dyspareunia in women undergoing either a transobturator (TO) or retropubic (RP) sling. STUDY DESIGN: We conducted a retrospective cohort study comparing women treated with either a TO or RP sling during a 10-month period. RESULTS: A total of 25 TO sling patients and 28 RP sling patients were compared in the study. Paraurethral banding was observed in 13/25 (52%) of the TO group compared with none in the RP group (P<.001). Although no difference was noted in overall female sexual function index scores, de novo internal dyspareunia was reported in 4/17 (24%) of the TO group and none in the RP group (P=.04). Paraurethral banding was observed in all patients reporting dyspareunia. CONCLUSION: We have identified paraurethral banding as a previously unreported complication of the TO sling. Surgeons should be aware of paraurethral banding and subsequent internal dyspareunia as a potential complication.

Bowel perforation during retropubic sling procedure.

BACKGROUND: Bowel perforation is a rare complication of tension-free vaginal tape (TVT)-type sling procedures and has been reported in patients with a previous history of abdominal or pelvic surgery. CASE: A 77-year-old woman with no prior history of abdominal or pelvic surgery underwent elective surgery for pelvic organ prolapse with a vaginal vault colpocleisis and suburethral sling. On postoperative day 2, a computed tomography scan performed for suprapubic discomfort showed an enterocutaneous fistula, which was treated surgically. CONCLUSION: Bowel perforation is a complication of TVT-type slings in patients with or without prior abdominal or pelvic surgery. High clinical suspicion, prompt identification, and surgical intervention allowed for a favorable outcome in this case.

Vesico-uterine fistula after endometrial ablation in a woman with prior cesarean deliveries.

BACKGROUND: Impedance-controlled endometrial ablation is a common procedure for menorrhagia in premenopausal women with relatively few contraindications. CASE: A 54-year-old woman with an obstetric history significant for three prior low transverse cesarean deliveries reported a constant drip of urine from the vagina beginning approximately 2 weeks after impedance-controlled endometrial ablation for menorrhagia. Evaluation confirmed a vesico-uterine fistula in the area of the prior cesarean delivery scars. The patient underwent a successful repair of the fistula using the abdominal approach. CONCLUSION: Vesico-uterine fistula may be associated with impedance-controlled endometrial ablation in women with prior low transverse cesarean deliveries.

Does vaginal size impact sexual activity and function?

INTRODUCTION AND HYPOTHESIS: This study seeks to determine if total vaginal length (TVL) or genital hiatus (GH) impact sexual activity and function. METHODS: Heterosexual women >or= 40 years were recruited from urogynecology and gynecology offices. TVL and GH were assessed using the Pelvic Organ Prolapse Quantification exam. Women completed the Female Sexual Function Index (FSFI) and were dichotomized into either normal function (FSFI total > 26) or sexual dysfunction (FSFI

Advanced anterior vaginal wall prolapse is highly correlated with apical prolapse.

OBJECTIVE: The purpose of this study was to determine the relationship between the most prolapsed portion of the anterior and posterior vaginal walls and the apex. STUDY DESIGN: After obtaining institutional review board approval, demographic data and pelvic organ prolapse quantification findings from consecutive new patients who were seen at our urogynecologic practice between January 2004 and February 2005 were reviewed. RESULTS: Three hundred twenty-five women were included in this cohort. The support of the vaginal apex (pelvic organ prolapse quantification point C) correlated strongly with the most prolapsed portion of the anterior vaginal wall, Ba (Spearman's rho = 0.835; P < .001) and correlated moderately with the most prolapsed portion of the posterior vaginal wall, Bp (Spearman's rho = 0.556; P < .001). A strong linear relationship was found between C and Ba, which is best modeled by the following regression equation: C = Ba(1.4) - 4.4 (r = .869). CONCLUSION: Anterior vaginal wall prolapse is associated strongly with apical prolapse. Anterior vaginal wall defects that are surgically repaired usually require a concomitant repair of the apex.