Risk perceptions, decisions, and treatment preferences in IVF: A mixed methods study

Abstract

Experiences of infertility are increasingly common with one in four couples now struggling to conceive naturally in New Zealand. In some cases, couples who desire a biological child will seek help from assisted reproduction and undergo in vitro fertilisation (IVF). IVF is, however, a highly complex medical procedure with uncertain outcomes and numerous associated mental and physical health risks. While some fertility-related risks can be objectively quantified (i.e. probability estimates), it is the subjective risk perceptions that patients live with and, at least in theory, will seek to mitigate. Of particular interest here is the fact that while current clinical practice suggests that clinicians should transfer the highest quality blastocyst(s) with the best chances for successful implantation, patients may only have a marginal blastocyst available and implantation potential may be uncertain. Nonetheless, a decision must be made. Prospective parents must then make these difficult and clinically uncertain decisions while evaluating and juggling different types of treatment-related risk. The current study is the first to develop and preliminarily evaluate a tool to assess patients concerns regarding IVF risks (IVF Concerns Questionnaire (IVFCQ)) and empirically test which risks may be causally relevant to patients decision-making processes and preferences during fertility treatment. Specifically, in an online study, three major IVF risks (public or private financing, no or failed transfer history, and good or poor future treatment prospects) were experimentally manipulated and their effects on a patient’s intention to transfer a marginal blastocyst as well as treatment preferences (who makes the decision, desire for additional treatment information, and regarding undergoing another oocyte pick-up (OPU)) tested. Patients who recently had or currently were undergoing IVF with Fertility Associates New Zealand were invited to complete the study online either anonymously or – should they consent to the medical record audit – confidentially. A total of 130 patients provided demographic information and completed a series of trait measures and the novel IVFCQ with 113 of those patients fully completing the eight decisional scenarios. Each scenario presented patients with a hypothetical scenario in which three risks were systematically manipulated – high/low financial risk, presence/absence of previous failed transfers, and poor/good chance of better blastocysts in the future – in conjunction with an image of the marginal blastocyst. Participants were asked how likely they were to transfer the blastocyst and their preferences for decisional autonomy, desire for additional treatment information, and likelihood of undergoing another OPU when future prospects were poor. Results from the structural examination validation of the IVFCQ indicated a clear separation between financial and non-financial risks. In tandem, financial risks consistently impacted decisional processes and preferences during treatment in the study’s experimental component. Specifically, privately financed fertility treatment and poor future prospects of obtaining better quality blastocysts were associated with a significantly higher intention to transfer the marginal blastocyst. Perhaps unsurprisingly, the presence of greater financial risk increased patient preferences for both decisional autonomy and desire for more treatment-relevant information but decreased preferences for another OPU. These findings suggest that in situations of uncertainty, subjective risk impacts both decisional processes and treatment preferences. Such findings highlight the need for clinicians to first acknowledge the fundamental importance of financial risk to their patients IVF journey and develop ways to help patients navigate these concerns in relation to their resources and treatment needs. To continue to improve the structure and delivery of clinical services, future work should further investigate the IVF-related risks that potentially drive patients decisional processes and treatment preferences as well as consider ways in which they might be addressed.