Patient identified factors influencing decisions to seek fertility care: Adaptation of a wellness model

Abstract

Objective:

To adapt a fertility care wellness model based on patient identified drivers and barriers.

Background:

Despite the availability of a range of diagnostic and therapeutic services for people affected by infertility, many do not seek care or discontinue care prior to achieving a live birth. Adapting wellness models to fertility care can inform research on patient decisions to seek and continue care, as many barriers and drivers are represented within the dimensions of wellness.

Methods:

A mixed methods online survey was completed by 135 men and women of reproductive age who experienced infertility in the USA. Main outcome measures included drivers and barriers to seeking or continuing fertility care. Identified factors were compared by treatment history using chi-square and Fisher’s exact tests. Themes and patterns were identified within the 174 responses to the 6 open-response items through conventional content analysis.

Results:

Thematic analysis of open responses revealed both practical (e.g., environmental, financial, and physical) and affective (e.g., emotional, social and spiritual) dimensions of wellness in the decision to seek care (67%), with affective rationales more prominent in the decision to return for care (78%).

Conclusion:

The decisions to initially seek fertility care and return after failed treatment integrate practical and affective rationales from financial, physical, environmental, emotional, social and spiritual wellness dimensions. Drivers and barriers within these dimensions should be considered to encourage care seeking and improve patient retention.

Introduction

Over 7 million women and their partners are affected by infertility in the United States (Chandra, Copen, & Stephen, 2014). In 2014, the Centers for Disease Control and Prevention (CDC) identified infertility as a public health issue, and in 2017 the American Medical Association joined the World Health Organization and the American Society for Reproductive Medicine in identifying infertility as a disease (Berg, 2017). Despite the availability of a range of effective diagnostic and therapeutic services for infertility, the 2006–2010 National Survey of Family Growth found that only 38% of infertile nulliparous women ever utilize these services, including basic medical advice (Chandra et al., 2014). While voluntary childlessness among some nulliparous women may contribute to the 62% of infertile nulliparous women who do not seek care, this is not considered a sufficient explanation for the observed underutilization of fertility services (Chandra et al., 2014; Greil, McQuillan, Johnson, Slauson-Blevins, & Shreffler, 2010). Griel and McQuillan (2004) have examined service utilization among women with infertility who have intent to conceive and found that nearly 50% never seek care. Furthermore, 13–48% of women who seek medical advice or fertility testing do not pursue treatment (Eisenberg et al., 2010; Greil & McQuillan, 2004), and 32% of women discontinue treatment before establishing a pregnancy and/or live birth (Farr, Anderson, Jamieson, Warner, & Macaluso, 2009). Discontinuation rates prior to success are high among those who undergo in vitro fertilization (IVF) treatment specifically, with multiple studies reporting that approximately 50% of those with unsuccessful treatment discontinue prior to achieving a live birth (McDowell & Murray, 2011; Olivius, Friden, Borg, & Bergh, 2004; Smeenk, Verhaak, Stolwijk, Kremer, & Braat, 2004).

Sociodemographic disparities have been identified as barriers to fertility care access (CDC, 2014; Missmer, Seifer, & Jain, 2011). Highly educated, affluent, urban, non-Hispanic white women are more likely to receive medical services related to infertility (Chandra et al., 2014; Jain & Hornstein, 2005; Smith et al., 2011). Cost is commonly cited as the major barrier to fertility care in general and IVF specifically (Eisenberg et al., 2010; Gameiro, Boivin, Peronace, & Verhaak, 2012; Nachtigall, MacDougall, Davis, & Beyene, 2012). At the time of this study, 15 of the 50 United States had legal mandates in place for varying degrees of insurance coverage for infertility care. While comprehensive insurance coverage can yield nearly a three-fold increase in IVF utilization (Jain, Harlow, & Hornstein, 2002), socioeconomic disparities persist, with income and education independently predicting fertility service use in those states with some degree of mandatory coverage (Eisenberg et al., 2010; Jain & Hornstein, 2005; Smith et al., 2011). Geographic disparities cause travel burdens that are often greatest in states without mandated insurance coverage. In Iowa, for example, only 53% of reproductive aged women live within 60 minutes of an IVF center (Nangia, Likosky, & Wang, 2010) and 19% of patients travel from census tracts of moderate to low accessibility to receive care (Gharani, Stewart, & Ryan, 2015).

Patients with infertility have identified access to emotional and social supports as important to their treatment experience and have prioritized these as important issues, along with practical considerations, for quality improvement initiatives (Dancet et al., 2010). The physical impact of treatment and the attendant intrusion into daily life are significant concerns related to patient dissatisfaction with treatment and premature discontinuation (Gameiro et al., 2012; Huisman, Raymakers, & Hoomans, 2009). The psychological stress of infertility along with the stress of treatment leads to increased levels of depression and anxiety in this patient population (Chan, Lau, Tam, & Ng, 2016; Merari, Chetrit, & Modan, 2002). Psychological distress, failure to become pregnant, and a sense of futility are primary reasons for discontinuation prior to a successful pregnancy (Domar, Rooney, Hacker, Sakkas, & Dodge, 2018; Eisenberg et al., 2010; Gameiro et al., 2012; McDowell & Murray, 2011; Rajkhowa, McConnell, & Thomas, 2006; Olivius et al., 2004; Smeenk et al., 2004; Takaki & Hibino, 2014). Cultural and religious factors also influence fertility care, though these effects are complex and vary depending on religious and cultural traditions (McQuillan, Benjamins, Johnson, Johnson, & Heinz, 2010).

Holistic definitions of health and wellness incorporate positive psychological, emotional, social, and spiritual factors as components which contribute to a multidimensional state of well-being, beyond physical absence of disease or illness. Wellness models present within both the behavioral health- and workforce wellness literature posit that wellness is multidimensional, composed of interconnected dimensions of wellness that intersect with each other in influencing an individual’s quality of life (Substance Abuse and Mental Health Services Administration [SAMHSA], n.d.; Hettler, 1976). Hettler’s model identifies emotional, occupational, physical, social, intellectual, and spiritual dimensions of wellness that contribute to holistic health and well-being. SAMHSA’s model expands on Hettler’s through the addition of financial and environmental dimensions. Adaptation and application of these models to fertility care is appropriate and informative, as many factors that impact fertility care are represented by dimensions of wellness within these models. An adapted wellness model allows us to consider how factors within various dimensions of wellness impact the holistic wellness of patients experiencing infertility, and how these integrated factors impact decisions to seek and return for care. In order to adapt a wellness model for fertility care, we have examined patient identified drivers and barriers to seeking and returning for ongoing care.

Materials and Methods

Participants

As we aimed to examine barriers and drivers to initiation and continuation of fertility care in the USA, we targeted recruitment of four groups of participants: a) individuals who met criteria for infertility but had never sought care; b) individuals who sought evaluation for infertility, but did not proceed with recommended care; c) individuals who underwent IVF without success and did not return; and d) individuals who underwent IVF without success and returned for further treatment. Recruitment of group A involved postings in affiliated primary healthcare settings; mass emails to university students, faculty, and staff; Facebook advertisements; and posting on ResearchMatch.org. Review of records from a Midwestern fertility clinic identified 931 potential participants for groups B-D who sought care between 2005 and 2010. To meet inclusion criteria, individuals had to speak English, be between 20–55 years old, and have experienced infertility, defined as a period of at least one year of unprotected intercourse without pregnancy. Both men and women were eligible for participation and were surveyed individually. Identified individuals were provided information about the study via mass mailing. Surveys were collected from January 2013 through February 2014. Participants were provided $15 USD compensation for participation in the study. Participants provided verbal consent prior to receiving a link to the online survey. This study was approved by the University of Iowa Institutional Review Board.

Surveys were completed by 135 participants (45 men and 77 women, with gender self-identified). As this study included a convenience sample (group A) and survey responses were anonymous, it is not possible to calculate a response rate. Table 1 describes participant demographic characteristics. The majority of participants were married, heterosexual, Caucasian women who were employed full time. Respondents were most likely to be Protestant (44%) or Catholic (35%) then non-affiliated (11%) or of another religious affiliation (10%). Participant mean age was 39.4 (SD = 7.0 years).

Table 1.

Sample characteristics by treatment history

	Full Sample (n=135) %, mean ± SD	Never treated (n=17) %, mean ± SD	Treated (n=118) %, mean ± SD
Age	39 ± 7	37 ± 8	40 ± 7
Caucasian	94	77	96
Female	90	53	96
Heterosexual	98	94	98
Married	86	71	88
Employed full time	65	71	64
Graduate level education	46	35	48
Annual household income ≥$60,000	78	42	84
Religion
Protestant	44	46	44
Catholic	35	7	38
Not-affiliated	11	20	10
Other	10	27	8
Political Affiliation
Democrat	46	23	45
Republican	39	53	41
Other	15	23	14

Results presented as % for categorical variables, and as mean ± Standard Deviation (SD) for categorical variables.

Measures

The 26-item survey sought to determine demographics, geographic location, treatment history, perceptions of how factors impacted the initial decision to seek fertility treatment and, if applicable, the decision to return after an unsuccessful treatment cycle. Participants ranked the role of each factor in their decision making and rated items along a 5-point Likert scale from “very discouraging” to “very encouraging”. Six open response questions provided an opportunity for participants to add additional information or alternative explanations. The survey was determined to have face validity by the multidisciplinary research team and is provided in Appendix A.

Mixed Methods Data Analyses and Interpretation

Chi-square and Fisher’s exact tests were used to compare participants who did and did not undergo fertility treatment. Separate comparisons were made within the unsuccessful IVF treatment group between those who did and did not return for further treatment. All statistical tests were performed using SPSS version 25.0.

Conventional content analysis as described by Hsieh and Shannon (2005) was employed to identify themes and patterns within the open response data. Open coding was performed independently by two researchers blinded to the participant study group. Following initial coding, categories were grouped into broader emergent domains. These domains aligned with SAMHSA’s Eight Dimensions of Wellness model (n.d.) and Hettler’s Six Dimensions of Wellness model (1976): “practical,” consisting of the environmental, financial, occupational and physical dimensions, and “affective,” consisting of the emotional, intellectual, social and spiritual dimensions (Figure 1). Discrepancies in coding were discussed with a third investigator to reach consensus.

Figure 1 -.

Wellness model for reproductive decision making, adapted from SAMHSA’s Eight Dimensions of Wellness model and Hettler’s Six Dimensions of Wellness model.^a

^a Additions to the model noted in italics.

Results

Participant Characteristics

Participants were grouped into tiers of care seeking based on treatment history (Supplemental Figure 1). Specifically, 17 (13%) reported never receiving fertility treatment and 118 (87%) reported receiving fertility treatment. Among those reporting unsuccessful IVF treatment, 28 (63%) reported returning for another IVF treatment cycle and 16 (36%) reported they did not return for further IVF care. Demographic characteristics of subgroups based on return for care after an unsuccessful IVF cycle are presented in Table 2. Geographic location of the study participants is plotted in Figure 2. Among participants who underwent IVF, 53% traveled more than 50 miles to receive care.

Table 2.

Subsample characteristics of those with an unsuccessful IVF treatment cycle

	Did not return after unsuccessful IVF cycle (n=16) %, mean ± SD	Returned for care after unsuccessful IVF cycle (n=28) %, mean ± SD
Age	45 ± 5	41 ± 5
Caucasian	94	93
Female	94	93
Heterosexual	100	100
Married	75	93
Employed full time	69	64
Graduate level education	56	36
Annual household income ≥$60,000	69	89
Religion
Protestant	20	35
Catholic	67	42
Not-affiliated	7	19
Other	7	4
Political Affiliation
Democrat	69	50
Republican	25	32
Other	7	18

Results presented as % for categorical variables, and as mean ± standard deviation (SD) for categorical variables.

Figure 2 –

Geographic location of study participants by treatment history. Insert maps show Iowa and Illinois. (A) Geographic location of all study participants by initial receipt of care. (B) Geographic location of study participants by return for IVF after an unsuccessful IVF treatment.

Factors Influencing the Decision to Seek Care

Drivers of seeking and returning for fertility care are shown in Table 3. Age was cited as the strongest driver for both seeking (30%) and returning to care (27%). Income was cited as the most discouraging factor for both seeking (23%) and returning to care (28%). Age was reported as the driver to seek or return for care at similar rates within all age groups (20–34, 35–39, 40–44, and 45+ years).

Table 3-.

Participant identified most influential factors in their decision to seek fertility care.

	Decision to seek care (n=135)		Decision to return for care (n=96)
	Classified as most encouraging driver	Classified as most discouraging barrier	Classified as most encouraging driver	Classified as most discouraging barrier
Age	30%	10%	27%	14%
Marital status	16%	1%	10%	0%
Location	11%	7%	5%	10%
Income	4%	23%	4%	28%
Other people in household	10%	2%	15%	4%
Othera	14%	13%	9%	7%
None of the above	15%	13%	30%	37%

^aResponse categories which were not selected by 10% or more of the sample as the most influential driver or barrier for seeking or returning for care were combined into other. Response categories included in other include: gender, education level, employment status, religious beliefs/faith, political affiliation, and language spoken at home.

When comparing responses by treatment category (treated vs. non-treated), age was cited as the strongest driver by both treated and non-treated participants (31% versus 24%; p=0.364) for initial care seeking. Non-treated participants cited household income as the most discouraging factor in their decision making more often than those who underwent treatment (47% versus 20%; p=0.026). Participants who had undergone treatment were more likely to indicate that none of the named factors were most discouraging in their decision to seek fertility care than participants who had not undergone treatment (48% versus 18%; p=0.040).

Among participants who underwent an unsuccessful IVF cycle and returned for care, age was cited as the strongest driver in their decision (31%), followed by other people in the participant’s household (19%) and “none of the above” (19%). Conversely, participants who did not return for ongoing care following unsuccessful IVF treatment most commonly indicated that none of the named factors were drivers in the decision not to return to care (69%). Both participants who did and did not return for ongoing care cited household income as the most discouraging factor in their decision (18% and 28%), although it was more common for both groups to indicate that none of the named factors was most discouraging (46% and 42%, respectively).

Adapted Reproductive Decision-Making Wellness Model

Conventional content analysis of the 174 responses (5,012 words) to six open response items revealed subthemes consistent with the physical, environmental, financial, emotional, social and spiritual dimensions of wellness described by SAMHSA (n.d.) and Hettler (1976). Two wellness dimensions described by SAMHSA (n.d.) and Hettler (1976) were notably missing from participants’ open responses. References to both the occupational dimension, defined as personal satisfaction within one’s career, and the intellectual dimension, defined as creative and stimulating mental activities, were not observed within participant responses and, therefore, were not included in our adapted wellness model for reproductive decision making (Figure 2). Remaining subthemes (physical, environmental, financial, emotional, social, and spiritual dimensions) were grouped into two main domains of practical (physical, environmental and financial) and affective rationales (emotional, social, and spiritual) through conventional content analysis (Hsieh & Shannon, 2005).

Utilizations of Practical vs. Affective Rationale

Differences in domains cited within participant rationales were observed between fertility treatment stages (Table 4). For the initial decision to seek care, both practical and affective domains were present in 67% of participants’ responses while 17% cited rational within the affective domain alone. When describing the decision to return for care, both practical and affective domains were present in 39% of participants’ responses and another 39% cited rational within the affective domain alone.

Table 4-.

Participant utilization of wellness domains in decision-making process

	Practical rationale alone	Affective rationale alone	Combination of practical and affective rationales
Never treated	0%	0%	100%
Treated	19%	19%	63%
Didn’t return for care	14%	43%	43%
Returned for care	14%	57%	29%

Practical Domain:

Participants referenced facilitators and barriers to care within the financial dimension (insurance coverage, income, and expenses) as influential in their decision to initially seek and return for care after an unsuccessful cycle:

The fact that I had a good job with insurance that at least covered a piece of this and had the income to cover our portion of it. Seemed like we could afford to try to extend our family. (male, non-IVF treatment)

It was a financial burden, especially given our income at the time of less than $50,000. Besides the treatment costs, there was mileage and hotel expense. In addition, my spouse and I had to take multiple sick days off of work. (female, didn’t return for IVF after an unsuccessful IVF treatment)

Other considerations within the practical domain fell within the environmental (geographic distance) and physical dimensions (age and concern about health risks).

We lived just a few miles away from one of the best infertility clinics and we had great insurance coverage. We are truly blessed to be given these opportunities. (female, successful IVF treatment)

Scheduling appointments around my work schedule was challenging, especially since I had a decent distance to travel to and from appointments. There were days that I had to leave straight from a 12 hour shift at work to drive to the clinic without getting to sleep. It was pretty stressful. (female, non-IVF treatment)

I started seeking treatment at the age of approximately 31. I didn’t want to wait any longer to seek treatment because I didn’t want it to be too late to have a child. (female, non-IVF treatment)

Reading some articles, I became concerned about the possible long-term health risks of doing any infertility intervention and stopped. (female, non-IVF treatment)

Affective Domain:

Within the affective domain, emotional dimension factors (motivation and desire for pregnancy, a child, or family growth) were commonly referenced by participants as the strongest driver in their decisions to seek and return for treatment:

I wanted to have children and that was the only way it could happen. (female, returned after an unsuccessful IVF treatment)

I was at the point in my life where I wanted a child and it didn’t matter how far away the treatment center was or how much it would cost. My husband and I wanted a child. (female, non-IVF treatment)

I just knew I was supposed to be a mother and my world would not be right without a child. I had to keep going. (female, non-IVF treatment)

Other factors cited within the emotional dimension included embarrassment about infertility, the emotional toll of involuntary childlessness and fertility treatment, pain from pregnancy losses, and attitudes about treatment effectiveness.

The amount of stress with past pregnancies and past infertility treatment is also a big factor, I had just lost my daughter to still birth and I just knew it would be too emotionally difficult for me to proceed with IVF. (female, non-IVF treatment)

After my first unsuccessful IVF treatment, I decided not to go through the procedure again. I wasn’t really influenced by any of the factors above. The emotional toll was simply too much for me to try again. (female, didn’t return for IVF after an unsuccessful IVF treatment)

The most discouraging element was the risk of another miscarriage. My wife and I had two miscarriages and it was so hard to pick ourselves up mentally and emotionally. It got harder each time. (male, returned after an unsuccessful IVF treatment)

Social dimension factors included health of relationship with spouse/partner and social support both from participants’ immediate families and their wider social networks, including employers.

The health of your relationship also is a big factor in whether to continue on with IVF, in my case there were too many marital problems to go forward with it. (female, returned after an unsuccessful IVF treatment)

My husband is 43 and I am 40 and my husband does not want children or to adopt at this age and it breaks my heart every day to know that I have missed my chances to ever have a child. (female, never treated)

Working in a medical office that understood the need for continuing appointments was extremely helpful. (female, non-IVF treatment)

Fatalistic attitudes, ethical concerns, and religious doctrinal support for specific treatments were named among participants’ spiritual dimension considerations in their decision to seek treatment. In addition to citing fatalistic attitudes, participants cited religion as an example of a coping strategy and source of support in deciding whether to return for care.

I kept thinking maybe this wasn’t going to work since I was trying to play God. (female, returned after an unsuccessful IVF treatment)

Due to our religious beliefs, my husband and I struggled with the decision to do IVF and took counsel from our pastor. (female, successful IVF treatment)

My faith grew so incredibly strong going through the process of trying to start a family. I felt humbled by God and leaned on Him during my pain and suffering. I wanted to be a mom and my husband wanted to be a dad SO badly…and we knew it was completely in His hands. We feel very blessed by God. (female, successful IVF treatment)

Discussion

Fertility care decisions are multifaceted, complex and personal. Previous studies have identified sociodemographic disparities in access as well as personal psychological and emotional factors that have influenced patients’ decision to seek fertility care and/or to return after care has failed. While our results confirm that financial and physical factors of income and age are important in fertility care decision making (Eisenberg et al., 2010; Gameiro et al., 2012; Jain et al., 2002; Smith et al., 2011), we found that patients also self-identify more complex, inter-related factors in their decision-making process. Participants spontaneously described dynamic interaction of six of SAMHSA’s eight dimensions of wellness (n.d.) within their decision making. Based on these responses, we adapted SAMHSA’s Wellness model (n.d.) to represent salient factors for decisions regarding fertility care (Figure 1).

Practical concerns such as the financial impact of care and time commitment have long been quoted as main barriers to infertility care (Eisenberg et al., 2010; Gameiro et al., 2012; Jain et al., 2002). At the time of our survey administration, 14 out of 50 states in the USA had some form of mandated infertility insurance coverage (Nangia et al., 2010). While data collection was ending just as the Affordable Care Act (ACA) was signed into law in the USA, Devine, Stillman, and DeCherney (2014) suggested that it was unlikely that the ACA would expand access to fertility healthcare within the foreseeable future. It is, therefore, not surprising that the decision to seek treatment for infertility was strongly influenced by factors within the practical domain, with household finances and insurance status as crucial factors in patients’ decision-making process to initially seek care.

While age has always been a looming issue related to infertility, its categorization as a driver to both seek and return for care across all age groups is surprising. With a mean sample age of 39.4 years old, it might be expected that age would be classified as a barrier instead of a driver among those of advanced age. Misrepresentation of the impact of age on fertility and success rates of fertility treatments within the media may contribute to a misunderstanding of age-related fertility decline (Willson, Perelman, & Goldman, 2019). Tendencies of the general public to overestimate both the age at which women experience fertility decline and fertility treatment success rates (Kudesia, Chernyak, & McAvey, 2017; Peterson, Pirritano, Tucker, & Lampic, 2012) may further contribute to persistent optimism. As future studies continue to examine patient decision making related to infertility treatment, it will be important to consider why this misunderstanding persists and how to broaden our understanding to include male partner age effects.

Our findings of the importance of emotional factors within the affective domain to decisions to seek and/or return for care are in line with prior research describing the emotional toll of involuntary childlessness and fertility care (Chan et al, 2016; Domar et al., 2018; Merari et al., 2002; Rajkhowa et al., 2006; Smeenk et al., 2004). Similarly, our findings of the importance of factors within social and spiritual dimensions aligns with the literature on the effect of religious, cultural and relational factors on experiences of fertility care (Dancet et al., 2010; Missmer et al., 2011; Takaki & Hibino, 2014). Our study is unique in that we have adapted a model which incorporates both these factors from the affective domain along with factors in the practical domain to provide a holistic perspective on the decision-making process to seek or return for ongoing fertility care. Our study has laid groundwork for use of this model to inform future studies on drivers and barriers to care seeking by patients. While our study has explored the use of this model to describe the multi-dimensional nature of fertility care seeking, future studies are needed to explore and describe the relationships between these interconnected dimensions in the fertility care setting.

Our study is limited by a small response from those not receiving treatment (n=17) and those not returning for care after an unsuccessful IVF cycle (n=16), thus hampering our ability to draw conclusions using our quantitative data. As this is a particularly challenging population to reach and recruit, we believe this study provides insight into barriers and drivers to care seeking for this often unreached population. Future studies should further examine differences in integration of the dimensions of wellness in the decision-making process based on level of care sought.

Our study is further limited by an imbalance of female to male participants. Underrepresentation of men within research on infertility and on the psychological aspects of fertility treatment is common, as women undergo a disproportionate share of physical treatment protocols and, therefore, are more likely to be available and attainable as research participants. Our study design could be adapted in future studies to capture more male participants, either to further examine the male experience of fertility treatment and treatment decision making, or as part of a study of couples undergoing fertility treatment. Coordinating recruitment with reproductive urologists may be one way to improve male recruitment to future studies. Our anonymous survey design which assessed data at the individual level, rather than at the level of the couple, did not allow us to assess how many unique couples participated or how couple-level factors influence care seeking. Future studies should consider survey designs which allow integration of responses from both members of the couple to examine how partners influence each other’s perspectives on decision making.

Our use of a convenience sample may limit the generalizability of our findings. The majority of participants had undergone IVF treatment (64%), which may also limit generalizability for patients undergoing other fertility treatments. Additionally, our study population is predominantly Midwestern, Caucasian, female, heterosexual and married; therefore, cultural influences may be underrepresented in our results. The driver/barrier balance may be different in geographic regions, where physical distance is not as significant an issue, and in regions with other cultural influences; therefore, future studies should be conducted in other regions of the USA and other countries. Despite the potential for limited generalizability, we believe our findings are an important contribution to the literature as they confirm prior studies’ findings that factors within the affective domain are an important consideration for patient retention in fertility care. Furthermore, qualitative data from this study identified several domains within established wellness models that should be considered in development of questionnaires and interviews to further assess issues of patient access and retention for both IVF and non-IVF fertility care.

Recall bias was an issue in our study as well, as participants in groups B-D had received care 3–9 years prior to recruitment. Future studies should evaluate care decision-making processes in real time, though such studies will likely face similar issues in identifying participants who decide not to pursue any infertility evaluation or care. Given the methodologic challenges of such a study, and the highly impactful nature of decision making around fertility care, we feel that our results provide valuable and sophisticated insights.

In summary, patients seeking and returning to fertility care cite a myriad of factors that contribute to their decision making. These factors are largely represented by an adapted wellness model and include care-determinants in both the practical and affective domains, with greater influence afforded to the affective domain by patients considering a return to care. We encourage fertility care providers to address emotional, social, and spiritual dimensions in addition to factors within the practical domain, to improve patient wellness, retention and outcomes.

Supplementary Material

Supplemental Figure 1

Supplemental Figure 1- Study sample of men and women with infertility grouped by treatment history