BACKGROUND ART differs in effectiveness, side-effects, administration, and costs. To improve the decision-making process, we need to understand what factors patients consider to be most important. OBJECTIVE AND RATIONALE We conducted this systematic review to assess which aspects of ART treatment (effectiveness, safety, burden, costs, patient-centeredness, and genetic parenthood) are most important in the decision-making of patients with an unfulfilled wish to have a child. SEARCH METHODS We searched studies indexed in Embase, PubMed, PsycINFO, and CINAHL prior to November 2023. Discrete choice experiments (DCEs), surveys, interviews, and conjoint analyses (CAs) about ART were included. Studies were included if they described two or more of the following attributes: effectiveness, safety, burden, costs, patient-centeredness, and genetic parenthood. Participants were men and women with an unfulfilled wish to have a child. From each DCE/CA study, we extracted the beta-coefficients and calculated the relative importance of treatment attributes or, in case of survey studies, extracted results. We assessed the risk of bias using the rating developed by the Grading of Recommendations Assessment, Development and Evaluation working group. Attributes were classified into effectiveness, safety, burden, costs, patient-centeredness, genetic parenthood, and others. OUTCOMES The search identified 938 studies of which 20 were included: 13 DCEs, three survey studies, three interview studies, and one conjoint analysis, with a total of 12 452 patients. Per study, 47–100% of the participants were women. Studies were assessed as having moderate to high risk of bias (critical: six studies, serious: four studies, moderate: nine studies, low: one study). The main limitation was the heterogeneity in the questionnaires and methodology utilized. Studies varied in the number and types of assessed attributes. Patients’ treatment decision-making was mostly driven by effectiveness, followed by safety, burden, costs, and patient-centeredness. Effectiveness was rated as the first or second most important factor in 10 of the 12 DCE studies (83%) and the relative importance of effectiveness varied between 17% and 63%, with a median of 34% (moderate certainty of evidence). Of eight studies evaluating safety, five studies valued safety as the first or second most important factor (63%), and the relative importance ranged from 8% to 35% (median 23%) (moderate certainty of evidence). Cost was rated as first or second most important in five of 10 studies, and the importance relative to the other attributes varied between 5% and 47% (median 23%) (moderate certainty of evidence). Burden was rated as first or second by three of 10 studies (30%) and the relative importance varied between 1% and 43% (median 13%) (low certainty of evidence). Patient-centeredness was second most important in one of five studies (20%) and had a relative importance between 7% and 24% (median 14%) (low certainty of evidence). Results suggest that patients are prepared to trade-off some effectiveness for more safety, or less burden and patient-centeredness. When safety was evaluated, the safety of the child was considered more important than the mother’s safety. Greater burden (cycle cancellations, number of injections, number of hospital visits, time) was more likely to be accepted by patients if they gained effectiveness, safety, or lower costs. Concerning patient-centeredness, information provision and physician attitude were considered most important, followed by involvement in decision-making, and treatment continuity by the same medical professional. Non-genetic parenthood did not have a clear impact on decision-making. WIDER IMPLICATIONS The findings of this review can be used in future preference studies and can help healthcare professionals in guiding patients’ decision-making and enable a more patient-centered approach.

中文翻译：

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寻求不孕症医疗援助的患者治疗决策的驱动因素：系统评价


背景 ART 在有效性、副作用、管理和成本方面有所不同。为了改进决策过程，我们需要了解患者认为最重要的因素。客观和基本原理我们进行了本系统综述，以评估 ART 治疗的哪些方面 （有效性、安全性、负担、成本、以患者为中心和遗传父母身份） 在未实现生育愿望的患者的决策中最为重要。检索方法 我们检索了 2023 年 11 月之前在 Embase、PubMed、PsycINFO 和 CINAHL 中索引的研究。包括关于 ART 的离散选择实验 （DCE） 、调查、访谈和联合分析 （CA）。如果研究描述了以下两个或多个属性：有效性、安全性、负担、成本、以患者为中心和遗传父母身份，则纳入研究。参与者是未实现生育愿望的男性和女性。从每项 DCE/CA 研究中，我们提取 β 系数并计算治疗属性的相对重要性，或者在调查研究的情况下，提取结果。我们使用建议分级评估、制定和评价工作组制定的评级评估偏倚风险。属性分为有效性、安全性、负担、成本、以患者为中心、遗传亲子关系等。结果 检索确定了 938 项研究，其中 20 项被纳入： 13 项 DCE、3 项调查研究、3 项访谈研究和 1 项联合分析，共涉及 12 452 名患者。根据研究，47-100% 的参与者是女性。研究被评估为具有中度至高度偏倚风险（关键：6项研究，严重：4项研究，中等：9项研究，低：1项研究）。 主要限制是所使用的问卷和方法的异质性。研究在评估属性的数量和类型方面有所不同。患者的治疗决策主要由有效性驱动，其次是安全性、负担、成本和以患者为中心。在 12 项 DCE 研究中，有 10 项 （83%） 将有效性评为第一或第二重要因素，有效性的相对重要性在 17% 至 63% 之间变化，中位数为 34%（中等质量证据）。在8项评估安全性的研究中，5项研究将安全性视为第一或第二重要因素（63%），相对重要性范围为8%至35%（中位数23%）（中等质量证据）。在 10 项研究中，有 5 项研究将成本评为第一或第二重要，相对于其他属性的重要性在 5% 到 47% 之间（中位数 23%）（中等质量证据）。10项研究中有3项（30%）将负担评为第一或第二，相对重要性在1%至43%之间（中位数为13%）（证据质量低）。在五项研究中，以患者为中心是第二重要的研究（20%），相对重要性在7%至24%（中位数14%）之间（证据质量低）。结果表明，患者准备牺牲一些有效性以获得更高的安全性，或更少的负担和以患者为中心。在评估安全性时，孩子的安全被认为比母亲的安全更重要。如果获得有效性、安全性或更低的成本，则患者更有可能接受更大的负担 （周期取消、注射次数、就诊次数、时间）。 关于以患者为中心，信息提供和医生态度被认为是最重要的，其次是参与决策和由同一医疗专业人员进行的治疗的连续性。非遗传父母身份对决策没有明显影响。更广泛的影响 本综述的结果可用于未来的偏好研究，可以帮助医疗保健专业人员指导患者的决策，并实现更加以患者为中心的方法。