The trouble with IVF and randomised control trials: Professional legitimation narratives on time-lapse imaging and evidence-informed care

"We don't experiment with our patients!" An ethnographic account of the epistemic politics of (re)designing nursing work

This article draws on ethnographic research investigating experimental reform projects in local nursing practices. These are aimed at strengthening nursing work and fostering nurses' position within healthcare through bottom-up nurse-driven innovations. Based on literature on epistemic politics and critical nursing studies, the study examines and conceptualizes how these nurses promote professional and organizational change. The research draws on data from two pilot projects to show how epistemic politics frame the production and use of knowledge within reform efforts. The study finds that knowledge produced through such experimenting is often not considered valid within the contexts of broader organizational transitions. The nurse-driven innovations fail to meet established legitimate criteria for informing change, both among stakeholders in the nurses' socio-political environment, as well as within the nursing community. The research reveals that the processes inadvertently reinforce normative knowledge hierarchies, perpetuating forms of epistemic injustice, limiting both nurses' ability to function as change agents and healthcare organizations' capacity to learn.

Is the use of IVF add-on treatments driven by patients or clinics? Findings from a UK patient survey

There are conflicting narratives over what drives demand for add-ons. We undertook an online survey of IVF patients to determine whether patients perceive that use of IVF add-ons is driven by patients or practitioners. People who underwent IVF in the UK in the previous five years were recruited via social media Survey questions focussed on the roles of clinician offer and patient request, including who first suggested use of add-ons in IVF consultations, where patients first heard about them, and which information sources they trusted. From a total of 261 responses, 224 met the inclusion criteria. Overall, 67% of respondents had used one or more IVF add-ons, most commonly: time-lapse imaging (27%), EmbryoGlue (27%), and endometrial scratching (26%). Overall, 81% of the add-ons used were offered to participants by clinicians (compared to 19% requested by themselves). Half (54%) reported being offered add-ons during consultations, compared to 24% who initiated discussion about add-ons. Higher proportions of private patients reported being offered (90%), requesting (47%) and using (74%) add-ons than those with NHS funding (74%, 29%, 52%, respectively). The main limitations of this study are the small sample size, recruitment via a convenience sample, and the self-reported data capture which is subject to recall bias.

Accounting for complexity in healthcare innovation debates: Professional views on the use of new IVF treatments

Social scientists have long been interested in the forces and values driving healthcare innovation. The simultaneous rise of 20th century healthcare reforms, increased importance of evidence and upsurge in lay health activism have shaped modern medicine. On this backdrop, fertility care emerged in the 1970s. Recent developments reveal a contentious relationship between new fertility treatments and clinical evidence, with emerging technologies being used without conclusive evidence of effectiveness despite being sold to patients. Initial critiques of this phenomenon emphasise commercial interests as the culprit, suggesting that the problematic use of unproven treatments is mainly driven by the private sector. Here, we challenge this over-simplified view of IVF care. Drawing on a qualitative analysis of key documents and 43 in-depth professional interviews, this article identifies three main stakeholder approaches to new treatment adoption. We argue that viewpoints are anchored within three critical overarching 'modes of coordination' or core values in modern healthcare: efficiency, effectiveness and patient-centeredness. This analysis encourages a more contextualised overview of fertility care than previous literatures have afforded. The IVF case shows that an emphasis on private versus public clinic practices obscure similarities between the two along with the values motivating healthcare professionals' approaches to new treatments.

Patient and professional perspectives about using in vitro fertilisation add-ons in the UK and Australia: a qualitative study

OBJECTIVES

In vitro fertilisation (IVF) add-ons are additional procedures offered alongside an IVF cycle with the aim of improving live birth rates. They are controversial because of the paucity of evidence to support their efficacy and safety, alongside the additional financial cost they often pose to patients. Despite this, they are popular. However, there is limited qualitative research regarding their use. The aims of the VALUE Study were to understand the decision-making process surrounding using or recommending add-ons; report sources of information for add-ons; and explore concerns for safety and effectiveness when considering their use.

DESIGN

'VALUE' is a qualitative semistructured interview study using inductive thematic analysis of anonymised transcriptions.

SETTING

Participants were recruited from a broad geographical spread across the UK and Australia from public and private clinical settings.

PARTICIPANTS

Patients (n=25) and health professionals (embryologists (n=25) and clinicians (n=24)) were interviewed. A purposive sampling strategy was undertaken. The sampling framework included people having state-subsidised and private cycles, professionals working in public and private sectors, geographical location and professionals of all grades.

RESULTS

Patients often made decisions about add-ons based on hope, minimising considerations of safety, efficacy or cost, whereas professionals sought the best outcomes for their patients and wanted to avoid them wasting their money. The driving forces behind add-on use differed: for patients, a professional opinion was the most influential reason, whereas for professionals, it was seen as patient driven. For both groups, applying the available evidence to individual circumstances was very challenging, especially in the sphere of IVF medicine, where the stakes are high.

CONCLUSIONS

There is scope to build on the quality of the discourse between patients and professionals. Patients describe valuing their autonomy with add-ons, but for professionals, undertaking informed consent will be critical, no matter where they sit on the spectrum regarding add-ons.

TRIAL REGISTRATION

osf.io/vnyb9.

Patient informed choice in the age of evidence-based medicine: IVF patients' approaches to biomedical evidence and fertility treatment add-ons

With the increasing offer of fertility treatment by a largely privatised sector, which has involved the proliferation of treatment add-ons lacking evidence of effectiveness, In-Vitro Fertilisation (IVF) patients are expected to make informed choices on what to include in their treatment. Drawing on interviews with 51 individuals undergoing fertility treatment, this article explores patients' approaches to medical evidence interpretation and its role in their decisions to include add-ons. While most IVF patients share understandings of what counts as medical evidence, our findings show how their approaches also differ. Our analysis focuses on how patients negotiate the notion of medical evidence and its relation to other forms of experience or knowledge. We present four different approaches to evidence in IVF: (1) delegating evaluations of evidence to experts; (2) critically assessing available evidence; (3) acknowledging the process of making evidence; and (4) contextualising evidence in their lived experience of infertility. We suggest that patients' choice to include add-ons is not due to a lack of information on or understanding of evidence, but rather should be interpreted as part of the complexity of patients' experiences of infertility.

Predicting Success in the Embryology Lab: The Use of Algorithmic Technologies in Knowledge Production

This article analyzes local algorithmic practices resulting from the increased use of time-lapse (TL) imaging in fertility treatment. The data produced by TL technologies are expected to help professionals pick the best embryo for implantation. The emergence of TL has been characterized by promissory discourses of deeper embryo knowledge and expanded selection standardization, despite professionals having no conclusive evidence that TL improves pregnancy rates. Our research explores the use of TL tools in embryology labs. We pay special attention to standardization efforts and knowledge-creation facilitated through TL and its incorporated algorithms. Using ethnographic data from five UK clinical sites, we argue that knowledge generated through TL is contingent upon complex human-machine interactions that produce local uncertainties. Thus, algorithms do not simply add medical knowledge. Rather, they rearrange professional practice and expertise. Firstly, we show how TL changes lab routines and training needs. Secondly, we show that the human input TL requires renders the algorithm itself an uncertain and situated practice. This, in turn, raises professional questions about the algorithm's authority in embryo selection. The article demonstrates the embedded nature of algorithmic knowledge production, thus pointing to the need for STS scholarship to further explore the locality of algorithms and AI.

Endometrial scratch to increase live birth rates in women undergoing first-time in vitro fertilisation: RCT and systematic review

BACKGROUND

In vitro fertilisation is a widely used reproductive technique that can be undertaken with or without intracytoplasmic sperm injection. The endometrial scratch procedure is an in vitro fertilisation 'add-on' that is sometimes provided prior to the first in vitro fertilisation cycle, but there is a lack of evidence to support its use.

OBJECTIVES

(1) To assess the clinical effectiveness, safety and cost-effectiveness of endometrial scratch compared with treatment as usual in women undergoing their first in vitro fertilisation cycle (the 'Endometrial Scratch Trial') and (2) to undertake a systematic review to combine the results of the Endometrial Scratch Trial with those of previous trials in which endometrial scratch was provided prior to the first in vitro fertilisation cycle.

DESIGN

A pragmatic, multicentre, superiority, open-label, parallel-group, individually randomised controlled trial. Participants were randomised (1 : 1) via a web-based system to receive endometrial scratch or treatment as usual using stratified block randomisation. The systematic review involved searching electronic databases (undertaken in January 2020) and clinicaltrials.gov (undertaken in September 2020) for relevant trials.

SETTING

Sixteen UK fertility units.

PARTICIPANTS

Women aged 18-37 years, inclusive, undergoing their first in vitro fertilisation cycle. The exclusion criteria included severe endometriosis, body mass index ≥ 35 kg/m² and previous trauma to the endometrium.

INTERVENTIONS

Endometrial scratch was undertaken in the mid-luteal phase of the menstrual cycle prior to in vitro fertilisation, and involved inserting a pipelle into the cavity of the uterus and rotating and withdrawing it three or four times. The endometrial scratch group then received usual in vitro fertilisation treatment. The treatment-as-usual group received usual in vitro fertilisation only.

MAIN OUTCOME MEASURES

The primary outcome was live birth after completion of 24 weeks' gestation within 10.5 months of egg collection. Secondary outcomes included implantation, pregnancy, ectopic pregnancy, miscarriage, pain and tolerability of the procedure, adverse events and treatment costs.

RESULTS

One thousand and forty-eight (30.3%) women were randomised to treatment as usual (n = 525) or endometrial scratch (n = 523) and were followed up between July 2016 and October 2019 and included in the intention-to-treat analysis. In the endometrial scratch group, 453 (86.6%) women received the endometrial scratch procedure. A total of 494 (94.1%) women in the treatment-as-usual group and 497 (95.0%) women in the endometrial scratch group underwent in vitro fertilisation. The live birth rate was 37.1% (195/525) in the treatment-as-usual group and 38.6% (202/523) in the endometrial scratch group: an unadjusted absolute difference of 1.5% (95% confidence interval -4.4% to 7.4%; p = 0.621). There were no statistically significant differences in secondary outcomes. Safety events were comparable across groups. No neonatal deaths were recorded. The cost per successful live birth was £11.90 per woman (95% confidence interval -£134 to £127). The pooled results of this trial and of eight similar trials found no evidence of a significant effect of endometrial scratch in increasing live birth rate (odds ratio 1.03, 95% confidence interval 0.87 to 1.22).

LIMITATIONS

A sham endometrial scratch procedure was not undertaken, but it is unlikely that doing so would have influenced the results, as objective fertility outcomes were used. A total of 9.2% of women randomised to receive endometrial scratch did not undergo the procedure, which may have slightly diluted the treatment effect.

CONCLUSIONS

We found no evidence to support the theory that performing endometrial scratch in the mid-luteal phase in women undergoing their first in vitro fertilisation cycle significantly improves live birth rate, although the procedure was well tolerated and safe. We recommend that endometrial scratch is not undertaken in this population.

TRIAL REGISTRATION

This trial is registered as ISRCTN23800982.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 10. See the NIHR Journals Library website for further project information.

Time-Lapse Systems: A Comprehensive Analysis on Effectiveness

Time-lapse systems have quickly become a common feature of in vitro fertilization laboratories all over the world. Since being introduced over a decade ago, the alleged benefits of time-lapse technology have continued to grow, from undisturbed culture conditions and round the clock, noninvasive observations to more recent computer-assisted selection of embryos through the development of algorithms. Despite the global uptake of time-lapse technology, its real impact on clinical outcomes is still controversial. This review aims to explore the different features offered by time-lapse technology, discussing incubation, algorithms, artificial intelligence and the regulation of nonessential treatment interventions, while assessing evidence on whether any benefit is offered over conventional technology.

Enacting evidence-based medicine in fertility care: Tensions between commercialisation and knowledge standardisation

In this article we explore the recent enactment of evidence-based medicine (EBM) in the field of fertility care. We aim to contribute to the medical sociology literature through an analysis of how evidence is produced, interpreted and institutionalised in a relatively new medical field such as in vitro fertilisation (IVF), characterised by high uncertainty due to limited knowledge and high levels of commercialisation. Drawing on extensive ethnographic research conducted in England, this article explores the challenges IVF professionals encounter in producing credible data on the effectiveness of additional treatments, offering novel insights on the tensions between commercialisation and standardisation in the enactment of EBM. Extant medical sociology and Science and Technology Studies literature has shown the hidden professional work required to enact randomised control trials in practice. Our analysis shows that this hidden work is not enough when there is a broader lack of standardisation in both clinical and research practices, as producing 'good quality' evidence requires high levels of standardisation of knowledge production.

Experiences of trial participants and site staff of participating in and running a large randomised trial within fertility (the endometrial scratch trial): a qualitative interview study

OBJECTIVES

To explore the experiences of endometrial scratch (ES) trial participants and site staff of trial recruitment and participation, in order to improve the experience of participants in future trials.

DESIGN

Qualitative study of a subset of participants in the ES randomised controlled trial and a subset of trial site staff.

SETTING

A purposeful sample of 9 of the 16 UK Fertility Units that participated in the trial.

PARTICIPANTS

A purposeful sample of 27 trial participants and 7 site staff.

RESULTS

Participants were largely happy with the recruitment practices, however, some were overwhelmed with the amount of information received. Interviewees had positive preconceptions regarding the possible effect of the ES on the outcome of their in vitro fertilisation (IVF) cycle, which often originated from their own internet research and seemed to be exacerbated by how site staff described the intervention. Some participants appeared to not understand that receiving the ES could potentially reduce their chances of a successful IVF outcome. Those randomised to the control arm discussed feeling discontent; site staff developed mechanisms of dealing with this.

CONCLUSIONS

A lack of equipoise in both study participants and the recruiting site staff led to trial participants having positive preconceptions of the potential impact of the ES on their upcoming IVF cycle. Trial participants may not have understood the potential harms of participating in a randomised trial. The trial information sheet did not clearly state this; further research should assess how such information should be presented to potential participants, to proportionately present the level of risk, but to not unduly discourage participation. The amount of information fertility patients require about a research study should also be investigated, in order to avoid participants feeling overwhelmed by the amount of information they receive prior to starting IVF.

TRIAL REGISTRATION NUMBER

ISRCTN23800982.

The crafting of hope: Contextualising add-ons in the treatment trajectories of IVF patients

The proliferation and popularity of additional treatments in IVF, also known as add-ons, has generated widespread discussion and controversy in the UK, where concerns have addressed the lack of evidence to support the efficacy and safety of these treatments, their cost, and their connection to a wider context of privatisation of fertility treatment. Drawing on 42 interviews with IVF patients, this article explores the role of hope in the appeal of add-ons from the patient perspective. The analysis is presented in two parts: firstly, we investigate the role of hope in patients' decision-making on treatment, contextualising add-ons in the broader trajectory of their IVF experience; secondly, we examine how patients navigate the offer of add-ons, focusing on the role of hope in how they rationalise their decisions on whether to include them in their fertility treatment. Our analysis shows how patients craft their hope to navigate the increasing number of available options in their quest to find the treatment(s) that will "work" for them. We suggest that the imperative for patients to explore all options is intensified with the emergence of add-ons, which produces a novel context and version of a "hope technology".