Friendly IVF: patient opinions

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1 Human Reproduction Vol.16, No.7 pp , 2001 Friendly IVF: patient opinions Astrid Højgaard 1,3, Hans Jakob Ingerslev 1 and Jakob Dinesen 2 1 Fertility Clinic and 2 Perinatal Epidemiological Research Unit, Department of Gynaecology and Obstetrics, Aarhus University Hospital, Skejby Sygehus, Aarhus, Denmark 3 To whom correspondence should be addressed at: Fertility Clinic, Skejby Sygehus, DK-8200 Aarhus N, Denmark. astrid.hoejgaard@dadlnet.dk BACKGROUND: The present trend towards low stimulation protocols in IVF calls for evaluation of patient attitudes. METHODS: This study compared results of a 23-item questionnaire mailed to 167 patients receiving a low stimulation type of regimen (L) (unstimulated cycle or clomiphene) and to 116 patients treated by a standard protocol () (long-down regulation with gonadotrophin-releasing hormone analogue and FSH or human menopausal gonadotrophin). RESULTS: Around two-thirds of all responders in both groups deemed sideeffects important, but side-effects and stress associated with hormone treatment were more prevalent in patients receiving than L. Stress due to cycle cancellation was acceptable, mild or not perceptible in significantly (P < 0.005) more patients receiving L [48% (36/75)] compared with patients having [26% (8/31)]. Of patients having tried the L protocol, 93% (125/135) would suggest either L or a sequence of this and as a future treatment package compared with only 53% (33/63) in the group (χ , P < ). The L group showed a significant trend towards acceptance of higher number of treatment cycles. CONCLUSIONS: The patients seemed to prefer the simplicity and short duration of a low stimulation regimen in spite of drawbacks such as a high risk of cycle cancellations and accordingly the necessity for more treatment cycles. Key words: clomiphene citrate/ivf/long down-regulation/unstimulated cycle Introduction cycles, and stress of cancelled cycles in order to point out problem areas and patient preferences in a low stimulation regimen compared with a standard long down-regulation protocol. As unstimulated IVF or low stimulation protocols implies a higher number of cancellations and consequently more treatment cycles (Ingerslev et al., 2001; H.J.Ingerslev et al., unpublished data), this study focused especially on the possible correlation between the number of cycles received and stress reported by the patients. During recent years attention has been given to hormone stimulation regimens less intensive than the long down-regula- tion protocol [gonadotrophin-releasing hormone (GnRH) ana- logue FSH or human menopausal gonadotrophin (HMG)] in order to reduce side-effects, costs, risks and incidence of multiple pregnancy associated with the latter (Edwards et al., 1996; Fleming, 1996; Olivennes and Frydman, 1998). More cycle cancellations seem unavoidably associated with milder stimulation regimens compared to the long down-regulation protocol, but a comparable cumulative clinical pregnancy rate per embryo transfer was recently achieved in IVF using a clomiphene citrate protocol (H.J.Ingerslev et al., unpublished data). There appear to be no previous studies which have analysed patients acceptability of low stimulation protocols. Acceptability can be evaluated by measuring patient satisfac- tion and self-reported levels of stress where patient satisfaction can be defined as the recipient s reaction to the context, process and result of her service experience (Pascoe, 1983) and stress as the perceived meaning of an event and self-appraisal of the adequacy of coping resources (Cohen et al., 1995). Accord- ingly, it was the purpose of the present study to evaluate patients satisfaction and stress associated with each of the two types of protocol in terms of side-effects of hormone treatment, pain at oocyte retrieval, necessity of more treatment Materials and methods Two patient groups receiving either a low stimulation type regimen (clomiphene citrate or unstimulated IVF) or a long down-regulation protocol were approached by a questionnaire. In addition to treatment- specific questions they were asked general questions on subjects related to overall satisfaction with the clinic to evaluate if the two patient groups studied were comparable in this aspect. Low stimulation group (L) Among 564 couples waiting for IVF or intracytoplasmic sperm injection (ICSI) treatment, 196 were invited to participate in a randomized study of IVF in the natural cycle and following clomiphene citrate respectively. Of these, 29 did not respond, 35 were enrolled in a pilot study and finally 132 participated in a randomized study between IVF in unstimulated cycles versus clomiphene citrate stimulation (Ingerslev et al., 2001). For the present study, the 167 patients European Society of Human Reproduction and Embryology 1391

2 A.Højgaard, H.J.Ingerslev and J.Dinesen enrolled in the pilot study and the previously published series were selected, hereafter termed the low stimulation group (L). All Table I. Information in the questionnaire about main characteristics of the fulfilled the following criteria: age 35 years, infertility unexplained, low stimulation (L) and standard protocol () treatment protocols and results tubal or due to severe male factor with indication for ICSI, regular menstrual cycles ( 3 days), presence of two ovaries and no previous IVF treatment. Patient characteristics and principles for randomization L and the two protocols have been presented previously (Ingerslev Mild hormone stimulation (tablets) Strong hormone stimulation (daily et al., 2001). Following closure of the randomized study, all patients injections) were offered further treatments with clomiphene citrate. During 1997 Treatment duration 2 weeks Treatment duration 4 weeks and 1998, the 167 patients received a total of 452 L cycles of Few side-effects More side-effects Few oocytes at oocyte retrieval Many oocytes at oocyte retrieval which 153 were unstimulated IVF cycles and 299 were stimulated High risk of cycle cancellation (40%) Low risk of cycle cancellation with clomiphene citrate. (20%) In short, at entry to the study, patients were randomized by the Pregnancy rate per started Pregnancy rate per started sealed envelope method to either clomiphene citrate (Clomivid ; treatment 18% treatment 30% Astra, Albertslund, Denmark) 100 mg from cycle day 3 to day 7 or Pregnancy rate per embryo Pregnancy rate per embryo transfer 40% transfer 40% to IVF in the unstimulated cycle, but with timing of oocyte retrieval by human chorionic gonadotrophin (HCG) injection. All cycles were monitored by vaginal ultrasound. No routine endocrinology was performed, but from day 9 (unstimulated cycle) or 11 (clomiphene stress throughout IVF treatments. Three staff members at our fertility citrate) the patients were instructed to test a morning urine sample clinic (a nurse, an embryologist and a doctor) developed further for LH by a qualitative test (Clearplan, Unipath Ltd, Bedford, UK). relevant themes. The questions in the final questionnaire related to If positive, HCG was given the same morning and oocyte retrieval the latest treatment cycle (11 questions) and to satisfaction with the was performed the following morning. Oocyte retrieval was performed amount of information (eight questions) and preferences of treatment ultrasound-guided transvaginally with a single-lumen needle (Cook, (three questions). Finally, respondents were encouraged to comment Brisbane, Australia, 16G) 30 min after the patient had taken 1 g of on the treatment. Scores were measured on a five-point Likert-type paracetamol and 10 mg of diazepam orally. No other analgesia was scale. Satisfaction concerning information was rated on a scale as offered routinely. Laboratory culture and ICSI were performed as follows: very satisfied, satisfied, neutral/do not know, dissatisfied, previously described (Ingerslev et al., 2001). A maximum of two very dissatisfied. The respondents were asked to characterize the embryos were transferred by a Cook, catheter. No luteal phase information given as: too optimistic, realistic or too pessimistic. support was given. Measurement of serum HCG was performed Stress, physical pain and side-effects were rated in the following way: 2 weeks later and concentrations of 20 IU/l were considered unacceptably severe, severe, acceptable, mild, none. The importance of positive. Pregnant patients were routinely scanned 5 weeks after a question was measured on a three-point scale: very important, embryo transfer. important and unimportant. Since the patients in the two groups had no experience as to the alternative treatment protocol, a short neutral Long down-regulation or standard IVF group () description of L and regimens was offered in the Among all couples having received their first and subsequent IVF questionnaire (Table I). cycles following the long down-regulation protocol (GnRH analogue In a pilot study 10 couples were interviewed after having fulfilled and FSH or HMG) at our clinic during 1996, 1997 and 1998, 116 the questionnaire. It was confirmed that the topics were considered couples fulfilled the same criteria as outlined above for the L important and final alterations were made to the questionnaire. group (H.J.Ingerslev et al., unpublished data). The 116 women had Enclosed with the questionnaire was a stamped addressed envelope a total of 190 treatments during the period. and a letter in which the aims of the study were described, anonymity Following down-regulation by Suprefact (Hjechst Marion Roussel, was guaranteed and it was emphasized that participation was voluntary. Stockholm, Sweden) nasal spray (six times per day) from cycle day Non-responders were not r ed. 21 in the previous cycle, ovarian stimulation with FSH or HMG Statistical analysis [Humegon, Puregon (Organon, Oss, The Netherlands) or Gonal- The results of the questionnaire and background data were entered F ; Serono SA, Madrid, Spain] started 2 weeks later postmenstrually in a Statistics Package for Social Sciences (SPSS) database and at a standard dose of 150 IU per day. Follicular development was analysed by SPSS software. Bivariate associations were tested with monitored by vaginal ultrasound and HCG (Pregnyl ; Organon) was Student s t-test for continuous outcomes, and the χ 2 -test for independgiven h before oocyte collection at a follicular diameter of ence within contingency tables for dichotomous outcome. Statistical leading follicle(s) of 18 mm. Oocyte retrieval was performed under i.v. significance was defined as two-sided P The risk difference sedation with midazolam ( mg) and pethidine (25 50 mg) is presented with 95% confidence intervals (CI). and a paracervical block with lidocaine. Oocyte handling, ICSI and embryo culture and transfer was performed as previously described (Ingerslev et al., 2001). Luteal support was given i.v. as progesterone Results (Progestan ; Organon) 100 mg four times daily until the pregnancy The response rate was significantly higher in the L group test and, if that was positive, until the pregnancy ultrasound 3 (141/167 84%) compared with the group (66/116 weeks later. 57%; χ ; odds ratio (OR) 4.1; 95% CI ; P ). Questionnaire A 23-item questionnaire was designed in a process involving the General questions following steps. The literature was reviewed in order to identify The two responder groups showed a comparable and high issues of particular importance concerning the patient satisfaction and satisfaction (very satisfied or satisfied) with the written informa- 1392

3 Friendly IVF and patient acceptance Table II. Experiences of and attitudes to side-effects of hormone treatment L Table III. Experiences of, and attitudes to, pain associated with oocyte retrieval How were the side-effects of the hormone treatment? Unacceptable/severe (%) 4/75 (5) a 38/63 (60) How was the pain associated with the last oocyte retrieval? Acceptable/mild/not perceptible (%) 71/75 (95) 25/63 (40) Unacceptable/severe 45/130 (35) a 27/64(42) How important are side-effects for your overall view of treatment? Acceptable/mild/not perceptible (%) 85/130 (65) 37/64 (58) Important/very important (%) 59/101 (58) b 39/64 (61) How important is pain for your overall view of treatment? Unimportant (%) 42/101 (42) 25/64 (39) Important/very important (%) 51/127 (40) b 37/65 (57) How was the stress associated with hormone treatment? How was the level of stress associated with oocyte retrieval? Unacceptable/severe (%) 2/73 (3) c 15/65 (23) Unacceptable/severe (%) 38/131 (29) c 20/64 (31) Acceptable/mild/none (%) 71/73 (97) 50/65 (77) Acceptable/mild/not perceptible (%) 93/131 (71) 44/64 (69) L a χ [odds ratio (OR) 27.0; 95% confidence interval (CI) ; a χ , not significant (NS). P 0.001]. b b χ (OR 2.0; 95% CI ; P 0.03). χ (not significant). c c χ (NS). χ (OR 10.7; 95% CI ; P 0.001). L low stimulation IVF; standard IVF. L low stimulation IVF; standard IVF. the two groups (Table II). The total stress of the hormone tion given [L 137/141 (97%) versus 65/66 (98%)] treatment was acceptable, little or not perceptible by 97% and verbal information from the doctors [L 126/140 (71/73) of the L patients compared with 77% (50/65) of (90%) versus 58/65 (89%)], nurses [L 139/140 the patients (Table II). There was no significant differ- (99%) versus 64/65 (99%)] and embryologists [L ence between pregnant versus non-pregnant responders in 134/140 (96%) versus 60/64 (94%)]. Equal proportions either group regarding severity and importance of side-effects of couples in the two groups evaluated the information as (data not shown). satisfactory [L 139/141 (99%) versus 64/66 Pain (97%)] and the expectations of the two treatments from the Among all patients, 12/194 (6%) reported unacceptable pain information given to be realistic [L 131/141 (93%) (Table III). Although similar proportions of patients in the two versus 61/65 (94%)]. Accordingly, there was no apparent groups had experienced a very painful last oocyte retrieval bias in the self-selection of the responders in terms of general [L 45/130 (%) and 27/64 (42%)], they had satisfaction to items not directly related to the treatment. different views on the importance of pain. Significantly more The mean number of started cycles was 1.86 in the L patients in the control group regarded pain at oocyte group and 1.69 in the group. In the last treatment cycle, retrieval as an important factor influencing their view of the 72/139 (52%) of the responders in the L group had treatment than in the L group (Table III). The total stress embryos transferred compared with 59/65 (91%) in the connected with the oocyte aspiration procedure was the same group. These values are similar to those in the total series in the two groups, being acceptable, mild or not perceptible [L 201/452 (44%) versus 164/190 (86%)]. Accordingly, in a large majority of the patients [93/131 (71%) versus the responder group was representative of all the patients 44/64 (69%)] (Table III). The reported pain at oocyte retrieval in the two groups in both cases in terms of completed cycles. in both groups was of no difference in pregnant and non- In the latest cycle a positive pregnancy test was obtained pregnant responders (data not shown). by 25% (31/123) of L responders, significantly higher than the average pregnancy rate of 14% (61/452) in that group Attitudes connected to cycle cancellation and repeated cycles (χ ; OR 2.2; 95% CI ). In the group The stress due to cancellation of a cycle was reported acceptable, these values were 60% (39/65) and 31% (59/190; χ ; mild or not perceptible by a significantly higher proportion OR 3.3; 95% CI ). There was no significant difference of the patients in the L group [36/75 (48%)] compared between pregnant versus non-pregnant responders in either with the group [8/31 (26%)] (χ ; OR 2.7; 95% group in terms of satisfaction with the information given (data CI ; P 0.005). not shown). In the L group there were no changes in perception of severity of hormone side-effects with increasing number of Specific questions related to the two treatments cycles started. A large majority of patients still found sideeffects Side-effects acceptable even after two or three cycles (data not Among 75 L patients who had been treated with clomi- shown). In the treatment group, however, side-effects phene, few deemed side-effects unacceptable or severe but were more commonly reported as severe if exposed to treatment more than half of the patients in the group did so more than once (one treatment cycle 15/31 versus more than (Table II). The patients were asked about what importance one cycle 22/30; χ ; OR 2.9; 95% CI ; hormone side-effects had for their general view of the particular P 0.005). The opinion on pain seemed to be independent treatment. Hormone side-effects were assessed to be important of number of treatment cycles in both groups and the pain or very important by a comparable proportion of patients in reported was independent of number of oocytes aspirated (data 1393

4 A.Højgaard, H.J.Ingerslev and J.Dinesen Table IV. Preferences of future treatments according to treatment experienced Table V. Answers to question on how many of either low stimulation (L) cycles and standard protocol () treatments the patients would like to go through before giving up IVF treatment Would you suggest L patients patients No. of treatments before L patients (%) patients (%) giving up L treatment (%) 50 (37%) a 3 (5) treatment (%) 10 (7) b 30 (48) L Combination of the two (%) 75 (56) c 30 (48) 3 22/93 (24) 12/21 (57) Total /93 (66) 5/21 (24) a χ [odds ratio (OR) 11.8; 95% confidence interval (CI) ; 3 37/49 (76) 23/39 (59) P 0.001]. 6 8/49 (16) 11/39 (28) b χ (OR 0.1; 95% CI ; P ). c χ (not significant). Preference of 6 LS cycles in L versus patients, χ L low stimulation IVF; standard IVF. (OR 6.1; 95% CI ; P 0.001). Preference of 3 cycles in L versus patients, χ (not significant). not shown). There was no significant difference between pregnant versus non-pregnant responders in terms of attitudes number of L cycles (Table V). On the other hand, both to cycle cancellation (data not shown). groups preferred a limited number of cycles ( 3). The same trends were evident when the patients were asked Preference for mode of treatment in the future to indicate how many of either treatment type they would Being presented with crude statements about the two protocols prefer in a sequential combination of the two (data not shown). (Table I), the patients were asked about preferences of either protocol or a combination of the two protocols (for example, two L trials followed by two trials). Both groups Discussion preferred the treatment that they had experienced (Table IV). The main object of this study was to evaluate how the patients In both groups about half of patients would suggest a combination balance advantages and disadvantages of low stimulation of the two regimens. However, 93% (125/135) of the regimens in terms of unstimulated cycles or clomiphene for patients having tried the L protocol would suggest either IVF versus a long down-regulation protocol with GnRH L or a sequence of this and compared with only analogue and FSH. In broad terms, it was found that the 53% (33/63) in the group (χ ; OR 11.4; 95% patients seem to counterbalance the disadvantages of low CI ; P ). stimulation (less efficiency per cycle, more cancellations) by In the L group 74% (23/31) of responders with a the apparent advantages (e.g. few side-effects, short duration, positive pregnancy test opted for L in comparison with simplicity). 20% (17/86) of responders with a negative pregnancy test Primary domains of satisfaction with fertility treatment are (χ ; OR 11.7; 95% CI ; P ). Among general satisfaction with the clinic, number, duration and responders the future choices were not influenced by results of treatment and information regarding treatment type, the results of the treatment (data not shown). side-effects and prognosis (Sabourin et al., 1991), all of which In patients having had L, preference for treatment were different in the two treatment protocols in the present protocol was associated with the perceived pain at the latest study. IVF treatment is stressful (Collins et al., 1992) and oocyte retrieval. Thus, there was a trend to prefer alone unsuccessful treatment causes grievance and anxiety compar- or a combination of and L if the last oocyte able with that seen following pregnancy loss (Greenfield et al., retrieval had been painful [77% (33/43)] compared with 55% 1988). The most stressful time points during the procedure are (45/82) if pain was acceptable (χ ; OR 2.7; 95% CI oocyte retrieval, embryo transfer and the 2 week waiting ; P 0.02). The choices in the group were not period until the pregnancy test (Connolly et al., 1993; Boivin associated with the severity of pain at the last oocyte retrieval, et al., 1998), which are all experienced more frequently in an although this group had indicated pain as an important factor L protocol. influencing their view of the treatment. In comparison with IVF with GnRH analogue FSH, L or a combination was preferred by 83% (76/92) of low stimulation regimens require more cycles to obtain a patients who considered hormone side-effects as important, comparable pregnancy rate, primarily due to a higher cycle compared with 68% (45/66) who did not (χ ; OR 2.2; cancellation rate. Accordingly, the patients must undergo a 95% CI ; P 0.05). higher number of hormone treatment cycles and oocyte aspiration When the patients in the two groups were asked to decide procedures (Ingerslev et al., 2001; H.J.Ingerslev et al., how many of either L cycles or treatments they unpublished data). Low stimulation regimens, on the other could accept in case no pregnancy was achieved to go hand, are associated with less prominent hormone side-effects, through before giving up IVF treatment, there was a significant a minimal risk of ovarian hyperstimulation syndrome, a much trend for the L group to prefer a high number ( 6) of shorter duration of treatment and a reduction of the risk of L cycles, whereas the group preferred a lower multiple pregnancies. 1394

5 Friendly IVF and patient acceptance All respondents were generally satisfied with the information satisfaction and number of treatment commencements did not given. From other studies it is known that information is a reach significance (Sabourin et al., 1991). main topic of satisfaction with infertility management (Halman The questionnaire was designed to give an answer to the et al., 1993; Souter et al., 1998). question of whether a less efficient and thus often repeated The higher response rate to the questionnaire in the L treatment with a mild stimulation protocol is more or less group compared with the group may be explained by a stressful than a more efficient standard protocol with heavier higher motivation for a new approach in the former group. stimulation and side-effects. A significantly larger proportion This fact and a relative over-representation of patients with of patients found cycle cancellations stressful in the positive pregnancy tests among responders in both groups may group compared to the L group. The lesser cancellation be borne in mind in the interpretation of the results of this study. stress reported in the L group may in part be explained Hormone side-effects were found to be important by a large by the fact that there was no limit to the number of treatment majority of all responders irrespective of treatment experienced cycles in this group, while patients were only entitled and are thus a main point of interest. A majority of patients to three completed cycles. Nevertheless, a majority of in the group, but few of the patients receiving clomiphene patients preferred a limit of three cycles. Thus, in the citrate in the L group, reported severe side-effects. L group there was a marked tendency to accept more With increasing number of cycles the burden of adverse effects treatments than in the group. This indicates that repeated in the group was more intolerable. No such tendency treatments cycles are acceptable within a low stimulation could be shown in the L group where almost no patients protocol. reported side-effects. The fact is that a rather high proportion of L cycles The information on side-effects in Table I given to all are cancelled, primarily due to spontaneous ovulation (14%) couples as a part of the questionnaire represents a possible and fertilization failure (21%) (H.J.Ingerslev et al., unpublished bias towards the L protocol. The reason for presenting data). GnRH antagonists may be useful to obviate risk of Table I in the questionnaire was that the patients had experi- spontaneous ovulation in low stimulation protocols. ences with only one of the two treatment protocols. In order In conclusion, the present study indicates that a majority of to indicate preferences they had to be briefly informed about the infertile patients seem to accept the drawbacks of low the main differences between the two protocols in order to stimulation regimens in terms of cycle cancellations and make a more informed assessment of the options. The informa- accordingly the necessity of more treatment cycles against the tion was rather schematic. The response rate of 96% is advantages of such protocols in terms of few side-effects, interpreted as a sign of high motivation and thus validity. simplicity and short duration. These data thus demonstrate that In the current study, pain at oocyte retrieval was almost a large proportion of the patients are motivated for low identical in the two groups in spite of absence of i.v. analgesia stimulation protocols as an integrated part of available protocols administered in the L group. This could not be attributed for IVF. to the fact that L patients had fewer oocytes, as the severity of pain was independent of number of oocytes. While Acknowledgements a majority of patients regarded pain as important, LS- IVF patients claimed pain to be of less importance. Nevertheless The authors wish to thank clinical, paramedical and laboratory staff at the Fertility Clinic at Skejby Sygehus and at The Perinatal L patients showed a marked preference to treat- Epidemiological Research Unit, especially Marianne Leth and Bente ment if the last oocyte retrieval had been painful. A possible Jespersen for participation in the development of the questionnaire. explanation for this could be that L patients, knowing We are very grateful to The Danish Institute for Health Technology that they were participating in a study, wanted to retreat to a Assessment for funding (project no ). well-known treatment protocol when experiencing a stressful event such as a painful oocyte retrieval. Another possible References explanation could be that patients who experience a painful Abbey, A., Halman, L.J. and Andrews, F.M. (1992) Psychosocial, treatment oocyte retrieval may have a wish to optimize outcome of and demographic predictors of the stress associated with infertility. Fertil. this stage of the treatment procedure. This may reflect the Steril., 57, Boivin, J., Andersson, L., Skoog-Svanberg, A. et al. (1998) Psychological importance of a sufficient analgesia to this group and that reactions during in-vitro fertilization: similar response in husbands and painful oocyte retrieval seems to be a predictor of compliance wives. Hum. Reprod., 13, with treatment. On the other hand there was no sign of change Cohen, S.J., Kessler, R.C. and Underwood, G.L. (1995) Strategies for measuring stress in studies of psychiatric and physical disorders. In Cohen, in the perception of pain after several unsuccessful treatment S.J., Kessler, R.C., Underwood, G.L. (eds), Measuring Stress: A Guide for cycles. Oocyte retrieval can thus be repeated without increasing Health and Social Scientists. Oxford University Press, New York, pp the burden of unsuccessful treatments in L patients. Collins, A., Freeman, E.W., Boxer, A.S. and Tureck, R. (1992) Perceptions Previous studies have shown that first and third treatment of infertility and treatment stress in females as compared with males entering in vitro fertilization treatment. Fertil. Steril., 2, cycles are the most stressful (Slade et al., 1997). After an Connolly, K.J., Edelmann, R.J., Bartlett, H. et al. (1993) An evaluation of unsuccessful treatment cycle, 25% of women have a mild or counselling for couples undergoing treatment for in-vitro fertilization. Hum. moderate depression (Newton et al., 1990). The higher the Reprod., 8, Edwards, R.G., Lobo, R. and Bouchard, P. (1996) Time to revolutionize number of unsuccessful treatment cycles, the more stress ovarian stimulation. Hum. Reprod., 11, (Abbey et al., 1992; Connolly et al., 1993). However, in a Fleming, R. (1996) Time to revolutionize ovarian stimulation. Hum. Reprod., consumer satisfaction study the association between patient 11,

6 A.Højgaard, H.J.Ingerslev and J.Dinesen Greenfeld, D.A., Diamond, M.P. and Decherney, A.H. (1988) Grief reactions Pascoe, G.C. (1983) Patient satisfaction in primary health care: a literature following IVF treatment. J. Psychosom. Obstet. Gynecol., 8, review and analysis. Eval. Prog. Planning, 6, 185. Halman, J.L., Abbey, A. and Andrews, F.M. (1993) Why are couples satisfied Sabourin, S. Wright, J., Duchesne, C. et al. (1991) Are consumers of modern with infertility treatment? Fertil. Steril., 5, fertility treatments satisfied? Fertil. Steril., 6, Ingerslev, H.J., Højgaard, A., Hindkjaer, J. et al. (2001) A randomized study Slade, P., Emery, J. and Lieberman, B.A. (1997) A prospective, longitudinal comparing IVF in the unstimulated cycle with IVF following clomiphene study of emotions and relationships in in-vitro fertilization treatment. Hum. citrate. Hum. Reprod., 16, Reprod., 12, Newton, C.R., Hearn, M.T. and Yuzpe, A.A. (1990) Psychological assessment Souter, V.L. Penney, G., Hopton, J.L. et al. (1998) Patient satisfaction with and follow-up after in-vitro fertilization: assessing the impact of failure. the management of infertility. Hum. Reprod., 13, Fertil. Steril., 5, Olivennes, F. and Frydman, R. (1998) Friendly IVF: the way of the future? Hum. Reprod., 13, Received on November 1, 2000; accepted on March 19,