Patients’ and professionals’ barriers and facilitators of tailored expectant management in subfertile couples with a good prognosis of a natural conception

Boogaard, N.M. van den; Boogaard, E. van den; Bokslag, Anouk; Zwieten, M.C. van; Hompes, Peter G.A.; Bhattacharya, Siladitya; Nelen, W.L.D.M.; Veen, Fulco van der; Mol, BW

doi:10.1093/humrep/der175

Cited by 27 publications

(22 citation statements)

References 30 publications

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“…To structure the patient perspectives, domains were used to categorize the treatment decision factors. The layout of categorization (personal, procedural, professional, social and external domains) is reported in other studies [ 37 , 38 ].…”

Section: Discussionmentioning

confidence: 80%

Patients’ perspectives on urethral bulk injection therapy and mid-urethral sling surgery for stress urinary incontinence

et al. 2018

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Introduction and hypothesisThe aim of this study was to identify all treatment decision factors that determined the preference for peri-urethral bulk injection therapy (PBI) or mid-urethral sling (MUS) surgery in patients with primary stress urinary incontinence (SUI). Second, we explored what patients expect from treatment for SUI and whether patients would consider PBI as a primary treatment option.MethodsIn a qualitative design, 20 semi-structured, face-to-face interviews were conducted in women with primary SUI. Exclusion criteria were: previous PBI or MUS surgery; predominating urgency. Interviews were guided by three open-ended questions and a topic list. PBI treatment and MUS surgery were described in detail, and the efficacy was stated as 70% and 90%, respectively. Data saturation was reached when no new treatment decision factors were identified in three consecutive interviews. Interviews were audiotaped and fully transcribed. Thematic analysis by a coding process was done independently by two researchers.ResultsSixteen procedural, personal, professional, social and external treatment decision factors were identified. Regarding expectations about treatment for SUI, women believed ‘becoming dry’ was wishful thinking. The majority of patients accepted a small degree of persistent urinary incontinence after treatment. Regardless of their treatment preference, patients indicated that women should be informed about PBI as a primary treatment option.ConclusionPatients with primary SUI are open to PBI as an alternative treatment option even with lower cure rates compared with MUS surgery performed under general or spinal anesthesia. Patients indicated that women with primary SUI seeking treatment should be informed about PBI as a treatment option.

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Section: Discussionmentioning

confidence: 80%

Patients’ perspectives on urethral bulk injection therapy and mid-urethral sling surgery for stress urinary incontinence

et al. 2018

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“…The multifaceted implementation strategy, based on a barrier analysis among professionals and patients, will focus on three different levels: patient, professional, and organizational level [20]. The three levels and all associated tools are successively described here.…”

Section: Methodsmentioning

confidence: 99%

“…Among the professionals, limited knowledge about prognostic models and limited communication skills to convince the couple, both leading to a decision in favor of treatment, were recognized as main barriers. Facilitators experienced by the professionals were better management of patients’ expectations, local consensus, and the presence of a local protocol and local fertility meetings [11,20]. …”

Section: Introductionmentioning

confidence: 99%

Improving the implementation of tailored expectant management in subfertile couples: protocol for a cluster randomized trial

et al. 2013

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BackgroundPrognostic models in reproductive medicine can help to identify subfertile couples who would benefit from fertility treatment. Expectant management in couples with a good chance of natural conception, i.e., tailored expectant management (TEM), prevents unnecessary treatment and is therefore recommended in international fertility guidelines. However, current implementation is not optimal, leaving room for improvement. Based on barriers and facilitators for TEM that were recently identified among professionals and subfertile couples, we have developed a multifaceted implementation strategy. The goal of this study is to assess the effects of this implementation strategy on the guideline adherence on TEM.Methods/designIn a cluster randomized trial, 25 clinics and their allied practitioners units will be randomized between the multifaceted implementation strategy and care as usual. Randomization will be stratified for in vitro fertilization (IVF) facilities (full licensed, intermediate/no IVF facilities). The effect of the implementation strategy, i.e., the percentage guideline adherence on TEM, will be evaluated by pre- and post-randomization data collection. Furthermore, there will be a process and cost evaluation of the strategy. The implementation strategy will focus on subfertile couples and their care providers i.e., general practitioners (GPs), fertility doctors, and gynecologists. The implementation strategy addresses three levels: patient level: education materials in the form of a patient information leaflet and a website; professional level: audit and feedback, educational outreach visit, communication training, and access to a digital version of the prognostic model of Hunault on a website; organizational level: providing a protocol based on the guideline. The primary outcome will be the percentage guideline adherence on TEM. Additional outcome measures will be treatment-, patient-, and process-related outcome measures.DiscussionThis study will provide evidence about the effectiveness and costs of a multifaceted implementation strategy to improve guideline adherence on TEM.Trial registrationhttp://www.trialregister.nlNTR3405. This study is sponsored by ZonMW.

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“…Among the professionals, limited knowledge about prognostic models leading to a decision in favour of EM or treatment was recognized as the main barrier. A main facilitator mentioned by the professionals was better management of patients' expectations [26,27]. An implementation strategy focussing on these barriers and facilitators has been developed and this implementation strategy is being tested in a multicentre cluster randomised trial in the Netherlands (The Improvement study).…”

Section: Implementation Of Expectant Managementmentioning

confidence: 99%

The Role of Expectant Management for Couples with Unexplained Infertility

Boogaard

Veen

Mol

2015

Unexplained Infertility

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Infertility is defined as a failure to conceive after at least 1 year of regular unprotected intercourse [1]. It affects approximately 10 % of couples in their reproductive lives [2,3]. Unexplained infertility is defined as infertility without any demonstrable cause after the basic fertility workup, including assessment of ovulation, semen analysis and evaluation of tubal patency. The incidence of infertility is increasing in the developed world mainly due to postponement of maternity. After a basic fertility workup, about 25 % of couples will be diagnosed with unexplained infertility [4,5].As in unexplained infertility, a causal explanation for the failure of conception is by definition lacking; natural conception should never be excluded in couples diagnosed as such. Consequently, expectant management (EM) may be a good option, especially when the prognosis for natural conception is reasonable. The EvidenceA recent update of a Cochrane review on intra uterine insemination (IUI) for couples with unexplained infertility was published in 2012 [6]. One trial was included that compared IUI in a natural cycle with EM and showed no evidence of increased live births (334 women: OR 1.6, 95 % CI: 0.92-2.8).Two trials compared EM with IUI with ovarian stimulation (OS) and both concluded there was no evidence of a difference in pregnancy rate (in total 304 women: data could not be pooled) [6]. In the last comparison (IUI-OS versus EM) one large multicentre randomised controlled trial (RCT) from the Netherlands was included. This RCT randomised 253 couples with unexplained infertility and intermediate prognosis of natural conception between either 6 months of EM or immediate start with OS and IUI. Within 6 months, the ongoing pregnancy rate in the EM group was 27 % and in the OS group with IUI 24 % (RR 0.85 CI: 0.63-1.1) [7]. The couples were then treated according to the centre's standard protocol, usually OS with IUI, followed by IVF. Three years after randomisation, the cumulative ongoing pregnancy rates were 72 and 73 % for EM and OS with IUI, respectively (RR 0.99 (95 % CI: 0.85-1.1). The time of ongoing pregnancy also did not differ between groups (log-rank test, p = 0.98) [8]. An RCT from the UK included 334 couples with unexplained infertility that were randomised to EM, oral clomiphene citrate or unstimulated IUI. After 6 months, a live birth rate of 23 % was obtained in the IUI group versus 16 % in the EM group, which was not significantly different (OR 1.60, 95 % CI 0.92) [9].A systematic Cochrane review on in vitro fertilisation (IVF) for couples with unexplained infertility concluded that the added value of IVF in relation to EM or IUI with or without OS in couples with unexplained infertility has not been conclusively proven due to a paucity of data: only one trial with 51 women compared IVF with EM and the live birth rate per woman was significantly higher with IVF (45.8 %) compared to EM (3.7 %; OR 22, 95 % CI 2.5-189) [10].Thus, RCTs in couples with unexplained infertility comparing EM with IUI with or with...

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Patients’ and professionals’ barriers and facilitators of tailored expectant management in subfertile couples with a good prognosis of a natural conception

Abstract: We identified several barriers and facilitators which can be addressed to improve the implementation of TEM. These should be taken into account when designing future implementation strategies.

Cited by 27 publications

References 30 publications

Patients’ perspectives on urethral bulk injection therapy and mid-urethral sling surgery for stress urinary incontinence

Patients’ perspectives on urethral bulk injection therapy and mid-urethral sling surgery for stress urinary incontinence

Improving the implementation of tailored expectant management in subfertile couples: protocol for a cluster randomized trial

The Role of Expectant Management for Couples with Unexplained Infertility

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