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STUDY QUESTION: What are the experiences of women undergoing IVF who could not receive an embryo transfer because of failed fertilization or poor embryo development? SUMMARY ANSWER: No embryo transfer because of failed embryo development is associated with considerable emotional suffering and the need for an early appointment with a physician to obtain information on what went wrong and new alternatives. WHAT IS KNOWN ALREADY: The psychological and emotional impact of IVF treatments as experienced by IVF patients is well known, particularly following the failure to achieve pregnancy. STUDY DESIGN SIZE DURATION: A qualitative study running from January 2018 to April 2019 was carried out at one public and one private IVF clinic. The invitation to participate was sent to women within 1 month after the cycle failed. PARTICIPANTS/MATERIALS SETTING METHODS: The women undergoing IVF were diverse in terms of cause of infertility, age, number of previous cycles, country of birth and educational level. Nineteen of the 41 invited women who had experienced no embryo transfer because of non-fertilization or poor embryo development took part in a semi-structured interview. Data were analysed by thematic content analysis. MAIN RESULTS AND THE ROLE OF CHANCE: The master theme was identified as: 'Lost and lonely' organized in two main themes 'Experience of the event' and 'Perception of needs from healthcare providers'. Considerable emotional suffering was recognized after no embryo transfer. The need for support was expressed as to be offered an early appointment with a physician for information about what went wrong, looking at new alternatives and, for many women, providing information about counselling. LIMITATIONS REASONS FOR CAUTION: Only women participated, not partners. Of the women invited, 46% participated. Several declined to participate because of high levels of emotional stress. WIDER IMPLICATIONS OF THE FINDINGS: Patients undergoing IVF and not achieving embryo transfer due to poor embryo development are a vulnerable group. They need early feedback concerning reasons for failure and future alternatives. They also require psychological support. This ought to be offered by IVF clinics. STUDY FUNDING/COMPETING INTERESTS: The study was financed by grants from the Swedish state under the agreement between the Swedish government and the county councils, the ALF-agreement (ALFGBG-70940). It was also financed by the Local Research and Development Board for Gothenburg and Södra Bohuslän (VGFOUGSB-866771) and by Hjalmar Svensson's research foundation (HJSV-2017012). None of the authors declares any conflicts of interest. LARGE SCALE DATA: N/A.

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INTRODUCTION: Previous studies have mainly compared professionals' and patients' ratings of the importance of different care aspects, finding poor agreement between the groups concerning patient-centered quality of care. There is still little known about professionals' knowledge of how patients experience the quality of care they receive during in vitro fertilization (IVF) treatments. The aim of this study was to investigate how IVF healthcare professionals estimate patients' experience of patient-centered quality of care and if certain factors influenced the IVF professionals' perceptions and IVF patients' experience of quality of care. MATERIAL AND METHODS: All 16 IVF public and private clinics in Sweden participated in this cross-sectional study. A total of 268 IVF healthcare professionals and 3298 patients (women and men) undergoing IVF treatment between January and May 2015 participated by answering the validated questionnaire "Quality from the patients' perspective of in vitro fertilization treatment" (QPP-IVF). RESULTS: Healthcare professionals significantly underestimated patients' satisfaction with the patient-centered quality of care they received in all aspects measured. Both patients and professionals rated the most deficient factors to be "responsibility/continuity", "participation" and "availability". Healthcare professionals and patients belonging to private clinics evaluated patient-centered care as significantly better than professionals and patients at public clinics in almost all aspects measured. CONCLUSION: The results of this study will increase the professionals' understanding of the patients' experiences during IVF treatment and provide additional knowledge when identifying areas to prioritize to improve quality of care.

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STUDY QUESTION: Do men and women value the same aspects of quality of care during IVF treatment when measuring rates of importance by the validated instrument, quality from the patient's perspective of in vitro fertilization (QPP-IVF)? SUMMARY ANSWER: Women valued most aspects of care as significantly more important than their partner although men and women evaluated the importance of the different care factors in a similar pattern. WHAT IS KNOWN ALREADY: A few validated tools measuring patient-centred quality of care during IVF have been developed. Few studies of gender differences concerning experiences of patient-centred quality of care have been reported in the literature to date. STUDY DESIGN, SIZE AND DURATION: A two-centre study was conducted between September 2011 and May 2012. Heterosexual couples (n = 497) undergoing IVF were invited to complete a questionnaire before receiving the result of the pregnancy test. PARTICIPANTS/MATERIALS, SETTING, METHODS: In all, 363 women and 292 men evaluated quality of care by answering the QPP-IVF questionnaire. The measurements consisted of two kinds of evaluations: the rating of the importance of various aspects of treatment (subjective importance) and the rating of perceived quality of care (perceived reality). Comparisons between men and women on importance ratings and perceived reality ratings were performed both on factor (subscale) and single item levels by intra-couple analyses and corrected for age. A stepwise multiple logistic regression analysis was performed in order to select baseline variables independently predicting evaluation at factor level. MAIN RESULTS AND THE ROLE OF CHANCE: The response rate was 67.5%, with 363 women (74.2%) and 292 men (60.6%) completing the study. Both the woman and man responded in 251 couples. Women rated the different care aspects as significantly more important than their partner in all factors except the factor, 'Responsibility/continuity'. Both genders gave the factors, 'Medical care' and 'Information after treatment', the highest scores. At item level women rated the majority of items as significantly more important than men. Perceived reality for the majority of factors and items was similarly rated by men and women in the couples. For women, receiving embryo transfer, short duration of infertility, IVF as a method and number of previous cycles were independently correlated to the highest score of importance of certain factors. LIMITATIONS, REASON FOR CAUTION: The lower response rate of men compared with women (60.6 versus 74.2%, respectively) might have influenced the results through selection bias. Only patients who had adequate fluency in the Swedish language participated. WIDER IMPLICATIONS OF THE FINDINGS: This study is an important contribution in comparing the needs of men and women undergoing IVF treatments. The QPP-IVF instrument is a suitable instrument for revealing important care aspects identified by both men and women and a useful tool for stimulating patient-centred quality improvements within and between clinics. STUDY FUNDING/COMPETING INTEREST: The study was supported by the LUA/ALF agreement at Sahlgrenska University Hospital, Gothenburg, Sweden, and by Hjalmar Svensson's Research Foundation. None of the authors declared any conflict of interests.

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STUDY QUESTION: Is it possible to develop a trustworthy instrument to evaluate the patient's perspective on fertility care and to document fully all methodological steps, including validation? SUMMARY ANSWER: A validated instrument has been developed for both women and men undergoing assisted reproduction to monitor the quality of care on a regular basis, similar to live birth rates and other effectiveness data. WHAT IS KNOWN ALREADY?: Within fertility care, several instruments have been developed, but many have significant methodological problems and few have been validated. Most instruments focus exclusively on women and no questionnaires have been directed at women and men separately. STUDY DESIGN, SIZE AND DURATION: The questionnaire specific to IVF treatments (QPP-IVF) is based on the theoretical foundation of the validated general instrument, quality of care from patients perspective (QPP), for both women and men. The QPP-IVF was developed and validated by quantitative methods. A two-centre study ran between September 2011 and May 2012. PARTICIPANTS/MATERIALS, SETTING, METHODS: In all, 655 women and men participated. The measurements consisted of two kinds of evaluations: the rating of perceived reality of care and the rating of the subjective importance of various aspects of treatment. The questionnaire consisted of 43 items for women and 42 items for men. An exploratory factor analysis was performed for women for all items of subjective importance. Eigenvalue, explained variance and factor loading are given for each factor. Internal consistency of subscales was assessed by Cronbach's alpha, item discriminant validity and percentage scaling success. For external validity, a correlation with fertility quality of life (FertiQoL) was performed and for reliability, a test-retest analysis was carried out. Sensitivity analyses were performed by known-group analyses. All significance tests were two sided and conducted at the 5% significance level. MAIN RESULTS AND THE ROLE OF CHANCE: The QPP-IVF instrument, divided into four dimensions, seemed a valid and reliable way of measuring the quality of care from a patient's perspective, for both women and men. The item-scaling test confirmed 10 underlying factors, with scaling success in all subscales and Cronbach's alpha >0.70 for women in almost all subscales. It was somewhat lower for men but still acceptable. The external validity was acceptable, with significant correlation between QPP-IVF and FertiQoL. The test-retest analysis confirmed that QPP-IVF was a stable instrument, with intra-class correlation coefficients from 0.74 to 0.89 for women. Sensitivity analyses indicated a sensitive instrument. LIMITATIONS, REASON FOR CAUTION: The response rate to the questionnaire was 67.5%. Although considered acceptable in questionnaire studies, this response level might introduce a certain risk of selection bias. The questionnaire was developed and validated only in Sweden. WIDER IMPLICATIONS OF THE FINDINGS: The QPP-IVF may be of use for purposes of quality improvement and national comparisons. Future studies should focus on establishing the QPP-IVF as a valuable instrument for measuring the quality of care outside Sweden. STUDY FUNDING/COMPETING INTEREST: The study was supported by the LUA/ALF agreement at Sahlgrenska University Hospital, Gothenburg, Sweden and by Hjalmar Svensson's Research Foundation. None of the authors declared any conflict of interests.

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OBJECTIVE: To study donors' motivation and ambivalence before donation of gametes. DESIGN: Cross-sectional study. SETTING: Seven Swedish university hospital clinics. Sample. Of the 220 eligible oocyte donors and 156 eligible sperm donors who were approached, 181 (82%) oocyte donors and 119 (76%) sperm donors agreed to participate. METHODS: Gamete donors completed a questionnaire in the clinic prior to the donation. MAIN OUTCOME MEASURES: Motives and ambivalence towards donation. RESULTS: In general, gamete donors donated for altruistic reasons (95%). A greater percentage of oocyte than sperm donors had a personal experience of biological children, which motivated them to donate (65 vs. 32%). A greater percentage of sperm donors compared with oocyte donors were curious about their own fertility (24 vs. 9%), and they also believed that they were contributing what they regarded as their own good genes to other couples (45 vs. 20%). Prior to donation, potential sperm donors were more ambivalent towards donating than were oocyte donors (39 and 21%, p < 0.001). CONCLUSIONS: The motives to donate gametes are mainly altruistic. We conclude that men and women differ in their view towards donating gametes. Sperm donors had a higher degree of ambivalent feelings towards donation than oocyte donors.

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OBJECTIVE: A possible negative effect of pain-relieving analgesics used during oocyte retrieval on fertilization and embryo development has been discussed. This study examines whether alfentanil dosage adversely affects fertilization and/or embryo quality. STUDY DESIGN: In a retrospective observational study the effect of different doses of alfentanil on two primary endpoints, fertilization rate and good quality embryo (GQE) rate, were compared in 663 women. RESULTS: In group A (0.5mg alfentanil) mean fertilization rate was 0.6+/-0.3 versus 0.6+/-0.2 (P=0.678, adjusted P=0.937, 95% CI for the difference -0.041; 0.044) and mean GQE rate was 0.6+/-0.3 versus 0.5+/-0.3 (P=0.207, adjusted P=0.179, 95% CI for the difference -0.015; 0.078), respectively. A paired comparison of 65 women who underwent repeated IVF cycles found that, compared with 0.5mg alfentanil had no adverse effects on fertilization rate (mean difference 0.05+/-0.3, P=0.231, 95% CI -0.02; 0.12) or GQE rate (mean difference -0.02+/-0.4, P=0.970, 95% CI -0.12; 0.09). CONCLUSION: The amount of alfentanil is not associated with adverse effects on fertilization rate, embryo development, or clinical pregnancy rate, which is reassuring and indicates that women can be offered adequate pain relief.

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The aim of this observational two-centre study was to investigate different aspects of pain in oocyte aspiration in conjunction with IVF, whether the preoperative information to women was sufficient, and which factor(s) influenced a woman's sense of security. The study group comprised 124 women who underwent IVF treatment. The visual analogue scale (VAS) was used to measure pain, and multiple-choice questions were used to evaluate satisfaction and sense of security. The women rated expected pain significantly higher than mean pain during surgery (P < 0.0001). They would have accepted significantly more pain than they experienced (P < 0.0001). In a stepwise linear regression analysis, total dose of alfentanil was the only variable that was independently associated with mean pain. Satisfaction with the preoperative information was high. Women considered staff competence to be important for their sense of security. In conclusion, women rated oocyte aspiration to be less painful than they expected before surgery. This is important information for women who are about to start IVF treatment, since it might reduce apprehension about the level of pain that could be expected during oocyte aspiration.

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BACKGROUND: A pre-ovarian block (POB) technique can be used for pain relief during oocyte retrieval in IVF. The local anaesthetic is deposited in the vaginal wall and between the vaginal wall and the peritoneal surface near the ovary using ultrasound guidance. The aim of this study was to test whether analgesia with POB resulted in improved pain relief compared to paracervical block (PCB). METHODS: A prospective, randomized, multicentre study of POB versus PCB (10 ml of 1% lidocaine each) with 183 patients randomized to POB (n = 96) or PCB (n = 87) was performed. Randomization (via a computer-generated list) was balanced for age, previously completed IVF cycles, degree of anxiety, estimated number of follicles, BMI, premedication and centre. Pain was measured using a visual analogue scale (VAS, 0-100 mm) and given as median values. The primary end-point of this study was overall VAS pain score for both sides during the oocyte retrieval procedure. RESULTS: Overall pain during the entire oocyte retrieval was 22 (POB) and 16 (PCB) (P = 0.42). No differences were found in degree of anxiety, premedication, dose of alfentanil, fertilization rate, number of good-quality embryos or clinical pregnancy rate. CONCLUSIONS: No differences were found in overall pain experienced during the entire oocyte retrieval procedure with POB compared to PCB.

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BACKGROUND: The primary aims were to compare the pain-relieving effect and post-operative well-being between electro-acupuncture analgesia (EA) and conventional analgesia (CA) comprising opiates. Further aims were to compare time for mobilization, and costs for time and drug consumption. METHODS: In all, 160 women undergoing IVF were randomized, according to a computer-generated list, to EA or CA. Well-being was evaluated with the State Trait Anxiety Inventory (STAI). Pain and subjective expectations and experiences were recorded on a visual analogue scale (VAS). Time and drug consumption were recorded. RESULTS: Although VAS pain ratings were significantly higher at oocyte aspiration (P < 0.0001) and after retrieval (P < 0.01) in the EA than in the CA group, they were similar 60 min after surgery. Both groups had similar STAI well-being scores. The EA group was significantly less tired and confused than the CA group after oocyte aspiration. No significant differences in time and costs for drug consumption were noted. CONCLUSION: EA cannot generally be recommended as a pain-relieving method at oocyte aspiration but might be an alternative for women desiring a non-pharmacological method. An advantage of EA is less post-operative tiredness and confusion compared with CA.

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