Decision making by patients seeking care for fertility problems

To describe how couples navigate infertility treatment decisions, including how they deliberate and reach consensus on plans for family building, how they adapt their plans as treatment progresses, and how they view past decisions.

Longitudinal, mixed-methods study on infertility decisionmaking among couples making an initial appointment with a reproductive specialist (RS) at an academic medical center in a Midwestern state without a health insurance mandate. We used interview and survey data to construct the treatment paths couples pursued considering financial and emotional resources and decision-making approaches.

Each member of 37 couples separately completed surveys and interviews up to 6 times during the year after making a first appointment; clinical data were abstracted from medical records. Data were managed/analyzed in REDCap, NVivo, and Stata. Written transcripts were systematically coded via standard procedures for content analysis (>10% double coded).

Through analysis of 414 interviews, we found that before an initial consultation with a RS most patients and their partners viewed gaining information as a key goal in meeting with a RS. Financial resources played an important role in shaping couples’ decision-making processes, and many respondents identified finances as an important constraint. Before their first appointment, 55% of respondents identified costs associated with trying to have a child as ‘‘quite a bit’’ or ‘‘very much’’ important to their decision-making, and that percentage increased to 64% after couples met with a RS. Couples able to purchase the care they desired generally moved relatively quickly both to consensus and to acting on their preferences. In contrast, couples whose finances were more constrained often delayed pursuing treatment that they otherwise agreed they would choose or worked together to identify a second-choice alternative that was financially feasible. Even as couples moved forward with one treatment path they often had a 2nd-choice alternative already in mind, as many were aware of the uncertainty associated with any given course of treatment. Finally, when looking back over the year, many supporting partners expressed regret at not being more involved along the way.

Understanding how couples reach consensus concerning plans for reproductive treatment holds promise to improve quality of care and increase long-term decisional satisfaction for patients and their partners. When couples first meet with a RS, most have not already made any decisions and are seeking information and advice. A key factor shaping couples’ abilities to reach agreement and proceed with treatment is their financial resources. Those who cannot afford their ‘‘first choice’’ often need the opportunity to ruminate and may appreciate input from the RS on next-best alternatives.