Assessment of environmental knowledge and needs among assisted reproductive technology professionals

Abstract

Purpose

Exposure to environmental contaminants is to be taken into account in preventive healthcare in general and particularly in the field of reproduction according to the increasing amount of evidence data being published. The aim of this study is to evaluate the practices and interest in and basic knowledge of environmental health, by the professionals of the ART process: doctor, embryologist, and nurses.

Methods

Survey among 12 Belgian assisted reproductive technology (ART) centers.

Results

The response rate was 67%: 43.5% of the ART professionals do bring up the topic of environmental contaminants with their patients, without significant differences among types of professionals. Ninety percent of respondents believe that it would be useful, and 63% mention their lack of knowledge and the absence of solutions (20.5%) to explain their inaction. Lack of knowledge is much greater for nurses respectively (85%) compared with doctors (52%) and biologists (54%). The most popular means toward improving their knowledge is scientific seminars (69%). The questionnaire to evaluate the health professional knowledge gives 56% of adequate replies. The topic concerning eating habits obtains a very bad score of knowledge. When looking at exposure to occupational risks, 75% of the answers were correct.

Conclusions

The place of ART before conception makes it an ideal entry point for the prevention of environmental hazards. This study corroborates the previous observations which underline the importance to reinforce the concepts of environmental health in the initial and continuous training of health professionals.

Introduction

Exposure to environmental contaminants is, at this time, seen as an important and even essential factor to be taken into account in preventive healthcare in general and particularly in the field of reproduction [1]. An increase number of scientific societies in the health and gynecology sphere agree to recommend special attention to environmental health following the accumulation of sufficiently robust evidence at the present time [2]. Their guidelines invite reproductive and other health professionals to advocate for policies to prevent exposure to toxic environmental chemicals [3].

Inhalation, ingestion, or muco-transcutaneous penetration of toxic agents during the periconceptional period could lead to harmful effects on fertility as well as nonhereditary, toxic effects on descendants [4, 5]. These considerations are based on Davis Baker’s hypothesis regarding the fetal origin of adult illness which has developed into the larger concept of Developmental Origins of Health and Disease (DOHaD) [6].

The susceptibility to such contaminants is particularly high during the periconceptional and perinatal period with potential consequences at different period of life. Potential effect on organogenesis exists and might be revealed at birth (cryptorchidism, hypospadias, cleft lip or palate) [7]. Epigenetic modifications can lead to illness in adulthood (higher incidence of testicular or breast cancer as well as cardiovascular disease) [8].

Furthermore, current data, some of which have a high level of evidence (EBM), have increasing data highlighting the harmful effect of environmental contaminants on both female and male fertility [9, 10].

This is why a preconceptional consultation is essential at the beginning of every parental project. This would indeed allow for two levels of prevention. On one hand, it could limit or even avoid exposure to agents suspected of affecting fertility and early pregnancy loss. On the other hand, it would provide necessary information before the pregnancy which could limit the harmful effects of potential environmental contaminants, in utero. Finally, it would allow parents to adopt healthy habits starting after birth. This period of vulnerability fits the World Health Organization’s (WHO) concept of the “first thousand days” which are a time of increased susceptibility, starting during the periconceptional days and the pregnancy and ending in early childhood [11].

Results of assisted reproductive technology (ART) generally peak at a pregnancy rate of 35.8% per embryo transfer [12]. Moreover, a number of failures are unexplained by the analysis of the usual criteria [13]. For these two reasons, a more global approach to patients’ infertility might constitute a new path toward improving ART prognosis. This approach would include the potentially harmful effects of environmental contaminants. To do this, both the medical and lifestyle history before treatment and information provided to patients before and during treatment could be the tools of this more global management.

Currently, Information is provided to patients, before treatment begins, at meetings in which physicians, nurses, and biologists take part. Although the role of the doctor is essential to explain the treatment prescribed, nurses are the main actors in the initial treatment management, and biologists are the ones who in the end present the final results according to observations of embryo’s development. This multidisciplinary approach to ART treatment justifies our interest in the opinions and knowledge of physicians, nurses as well as biologists who work in ART center.

The goal of this study is to better understand the practices and interest in and basic knowledge of environmental health, by the professionals who take part in the ART process.

Material and method

This is a prospective, observational study which analyzes the results from an anonymous survey of a target group of professionals involved in the ART process before conception.

Target population

All ART centers of the French-speaking area of Belgium were included: 8 B centers and 4 A centers as defined by Belgian law. B centers are allowed to perform all the ART procedures, while A center may obtain gametes but are obliged to transfer oocytes and sperm to a B center to achieve the ART procedure to embryo’s transfer. The department heads have been contacted to have their agreement and the email addresses of all their collaborators. 12/12 responded favorably and included the requested emails. The final population included 81 doctors, 61 specialized nurses, and 73 embryology biologists, all working in these 12 ART centers.

Contact and feasibility

After two additional emails sent 2 weeks apart, the email addresses of all targeted personnel of the French language ART centers were obtained. Authorization to conduct the study was given by the local ethics committee in accordance with the new European regulations regarding the protection of personal data from May 2018 (GDPR) received on April 10, 2019. Two emails, a week apart, will be sent (but no possibility of responding twice) to the 215 participants.

Web survey (Appendix Table 4)

Table 4.

Web questionnaire environment health and fertility

I would like to ask you some non-identifiable personal information:

Gender

•Male

•Female

Age

•Under 30

•Between 30 and 50

•Over 50

What is your job in ART?

•Nurse

•Biologist

•Doctor

How long have you been working in ART?

•Less than 5 years

•Between 5 and 10 years

•More than 10 years

During your professional practice in ART:

Do you address the issue of potential environmental toxicants with your patients (excluding addictions as tobacco, alcohol, and drugs)

•Routinely, during every initial consultation

•At the information session

•In case of unexplained failures of ART treatment

•Very rarely

•Never

Do you think that basic recommendations regarding exposure to endocrine disruptors and environmental toxicants are required before ART treatment?

•No, according to the lack of scientific knowledge

•Yes, and we have sufficient knowledge to correctly inform our patient

•Yes, but we are insufficiently trained/equipped to share knowledge on this topic

To inform your patients about the environment’s potential toxic effects, do you recommend the existing leaflets published in Belgium and France (French language)?

•Yes, they are very well designed

•No, I find them inappropriate

•I do not know these tools

Why do not you make recommendations if you think they could be helpful?

•Because of a lack of knowledge about the topic

•Fear of the patient’s reaction

•The lack of concrete solutions to reduce harmful exposures

•It is not my priority, and I do not have time to do it

•The information disclosed by the media is widely sufficient

•I do not feel concerned by the question as I regularly give this kind of information

To improve your knowledge about environmental health, which training method would you prefer?

•Appropriate seminars provided by scientific societies

•A university certificate with full curriculum for healthcare professionals

•A well-targeted and oriented website for professionals and patients

Now a little quiz of 20 questions, see Table 1

Do you recommend applications as INCI beauty and Clean Beauty to choose cosmetics during ART treatment?

•Yes

•No

•I do not know these applications

Do you know the French multidisciplinary consultation in environmental health of the perinatal period and their function?

•Yes

•No

•Dimly

Which professions expose the workers to toxic? See Table 3

Do you discuss the theories of Barker and Hales and DOHaD with your patients?

•Yes

•No

•I do not know these theories

Are you aware with the REACH regulation and the ECHA and do you check it in case of doubt about a potential toxic substance?

•Yes

•No

•I do not know these tools

1. Content: the questionnaire will determine various characteristics

• I.Respondents’ phenotype (age, gender, experience, job).
• II.Current practices pertaining to environmental health: Actions taken by each member of the team (at this time), use and understanding of existing tools, possible difficulties in including this knowledge and the reasons why, and opinion regarding the necessity/relevance of using such an approach.
• III.In order to determine the health professional’s scope of knowledge, questions regarding areas where a good level of evidence exists have been submitted with three possibilities of response: agree, do not agree, and do not know (Table 1).”
• IV.The content of this questionnaire about environmental contaminants is based on “Take Home Message” of the French university certificate in environmental health of Marseille, France. The current available data on environmental health information in preconceptional period were also reviewed to create the survey [7, 9, 14, 15, 17].
• V.Required learning mode to improve their knowledge.

• b)Form:

• I.Email requesting participation in a study (informed consent)
• II.Online questionnaire using a link given in the email
• III.Multiple choice questions (34 questions on three pages), duration 10 min
• IV.Anonymous management of the answers, specified in the email
• V.Two reminders at 7-day intervals

Table 1.

ART professionals’ level of knowledge

Questions	Expected answer	Correct	Wrong	Unknown
		Answer in %
1. Does the parent’s environment, before the transfer, impacts the fetus’s health?	Wrong	80	12	8
2. Ingestion or inhalation is the only exposure route for environmental contaminants	Wrong	93	4	3
3. Living in rural settings is without danger because of lower concentrations of microparticulates	Wrong	92	7	1
4. A pleasant smelling, disinfected interior is a guarantee of a healthy environment	Wrong	98	0	2
5. Scientific data can be used to recommend organic-labeled food before and during pregnancy	True	31	21	48
6. During ART treatments, the use of air fresheners, essential oils, or incense is recommended for relaxation	Wrong	71	6	23
7. Water pipes and gasoline no longer contain lead and therefore present no risk of lead poisoning	Wrong	76	0	24
8. Organic solvents are incriminated, with a high level of evidence, for their effect on male fertility and congenital malformations	True	50	5	45
9. Hair dye and nail polish use should be limited or banned before conception and during pregnancy	True	57	9	34
10. Pharmacy-sold or traditionally, artisan-made cosmetics are less risky than the ones sold in department stores	Wrong	39	13	48
11. Fish consumption should be limited to twice a week, excepted for freshwater fish which should be forbidden during ART treatment and pregnancy	True	21	16	63
12. Plastic containers are recommended as it allows to heat food easily in the microwave while preserving all of its vitamins and nutrients	Wrong	90	0	10
13. Peeled fruit does not have to be washed	Wrong	70	18	12
14. Outdoor air is less polluted than indoor air	True	19	59	22
15. Interior decorating work (nursery) should not be tolerated before and during pregnancy	True	45	18	37
16. It is recommended to wash textiles, drapes, and upholstery fabric before using them for the first time as they contain endocrine disruptors.	True	82	1	17
17. Silicone dishes should not be heated because they emit bisphenol A	Wrong	13	33	54
18. Because of their negative effect on reproduction, any exposure to bisphenol A and phthalates should be sought in the patient’s medical history, in cases of failed ART	True	50	4	46
19. Food and drink cans, made from aluminum, outside of the EEC, constitute a risk of exposure to bisphenol A	True	34	4	62
20. Currently, European regulations require all new chemical substances used by the general public to be tested for toxic components, based on a CMR classification (carcinogenic, mutagenic, reprotoxic)	Wrong	4	27	69

Answers based on recent published data [7, 9, 14–16]

Data processing and statistical analysis

Assessment of the response rate by category and by groups:

Quantitative data were extracted from the questionnaires and analyzed using Excel (Microsoft Redmond, WA, USA).

Analyses of the differences answers between professional roles:

Comparative analysis was performed using chi-square test analysis with a statistical significance set at P < 0.05.

Two software were used: http://www.aly-abbara.com/utilitaires/statistiques/khi_carre.html and https://www.socscistatistics.com/tests/chisquare2/default2.aspx.

Results

Two hundred and fifteen web questionnaires were sent on April 29, 2019, and then two reminders at 1-week intervals. Three pages including thirty-four questions were sent, and the percentage of completion of the questionnaire is 88% in an average time of 7 min and 45 s.

A 67% rate of response was attained with 144 questionnaires filled out.

Respondents’ phenotype (Fig. 1)

Fig. 1.

Respondents’ phenotype

The final population included 81 doctors, 61 specialized nurses, and 73 embryology biologists, all working in these 12 ART centers. The gender distribution is 176 women and 39 men. Eighty four percent of respondents are women even though they accounted for 82% of the surveyed population. More than 90% are older than 30, and more than 50% have more than 10 years of ART experience.

The distribution between the various professions is quite homogenous with, respectively: 39.6%, 34.5%, and 25.9% of doctors, biologists, and nurses. There is no difference in the response rate related to the participants’ functions within the ART team nor to their gender (P = 0.53).

Current practices pertaining to environmental health

These results are presented according to the structure of the survey (Appendix Table 4). One hundred and thirty-one participants (91%) answered the question, “Do you address the issue of potential environmental toxicants with your patients (excluding addictions as tobacco, alcohol, drugs)”. The answers proposed to this question were:

1. Routinely, during every initial consultation

2. At the information session

3. In case of unexplained failures

4. Very rarely

5. Never

More than one answer was allowed for this question. Forty-three percent (43.5%) of the health professionals do bring up the topic of environmental contaminants with their patients (giving positive answer to at least one of the 3 first questions). Seventy-five percent (75.4%) in this group systematically address it when taking medical histories and 17.5% only during the information session. Seven percent take into consideration the role that the environment could play in recurring failed attempts. Nevertheless, 56.5% never or rarely talk about it. Although 53% of physicians address this issue compared with 36 and 35% of biologists and nurses, this difference is not significant (P = 0.15).

One hundred and thirty-five participants (93.7%) answered the question: “Do you think that basic recommendations regarding exposure to endocrine disruptors and environmental toxicants are required before ART treatment?”

Among these 135 respondents, 121 (89.6%) believe that it would be useful to organize counseling about potentially toxic exposure. Ninety-two percent (91.7%) of them deem their training in this field to be insufficient to share knowledges on this topic. Only 10.4% of respondents feel that, at this time, there is no use in considering this aspect due to a lack of scientific evidences.

This opinion does not differ significantly between the professions (P = 0.4). Ninety-three percent of all of the health professionals are unfamiliar with the available tools for informing patients without statistical difference between the professions (P = 0.7). Only one respondent (physician) knows about these tools but finds them inadequate.

Those who think that this information would be helpful but do not provide it mention their lack of knowledge (63%) and bring up the absence of solutions to counter these environmental effects (20.5%) as main reasons. Only 1.5% fear the patients’ reactions, and no one feels that the media fill their role of informing the public. For 5.5% of respondents, giving such recommendations is not a priority, and they do not have time to do it. Nine and a half percent of respondents do not hesitate to provide as much information as they can. At this level, a significant difference (P < 0,004) is observed between the professions. Indeed, the lack of knowledge is much greater for nurses respectively (85%) compared with doctors (52%) and biologists (54%). The biologists seem to be the least concerned about this aspect according to their answers or lack thereof, respectively, 40% compared with 3.6% and 5.5% of physicians and nurses.

Required learning mode to improve knowledge

The most popular means toward improving their knowledge in this field is seminars, organized by the scientific community (69%). A well-targeted website for both professionals and patients is also a positive choice for 45% of respondents, and 11% would willingly take part in a university certification course. Thirteen percent of respondents expect no training at all because they consider that this issue is not part of the ART care to their patients. Training methods are also viewed differently from one profession to the other (P > 0,004) because insomuch as scientific societies’ seminars are chosen by a majority of the respondents (80% of nurses, 71% of doctors, and 48% of biologists), only the biologists (31%) feel that environment health should not be part of their function.

Extent of knowledge

Adequate replies were provided from 56% of the ART professionals, whereas 32% stated that they did not know the answer (Table 1).

Although the answers to two questions regarding eating habits (questions 5 and 11) obtained very low “correct answer” (31 and 21%), no specific field of knowledge can be singled out as less well-known than another. Indeed, if we group the different questions by themes (Table 2), none of them appears to be better or less understood by the respondents. The theme of the use of cosmetics (questions 9 and 10) obtains 57 and 39% of good answers, and 34 and 48% cannot answer to these questions. For the knowledge of the data concerning the toxicity of solvents (question 8), the rate of good answers does not exceed 50%. The quality of indoor air concept is not grasped by 60% of them. It should be noted that 69% of participants have no knowledge of European regulations in this domain (question 20).

Table 2.

Knowledge of ART professionals classified by topic

	Correct answer	Wrong answer	Answer = unknown
	Results (%)
Air quality	65	17	18
Food	41	18	41
Cosmetic	48	11	41
Endocrine disruptors	47	10	43
Atmospheric pollutants	69	2	29
General concepts	59	14	27

A majority of ART professionals (78%) do not encourage patients to protect themselves from the toxic elements found in cosmetics, using available web applications, because they are unfamiliar with them. Only 7% make such recommendations. In the same way, 81% are unaware of the existence of medical platforms which offer pluridisciplinary management of environmental health during the perinatal period, 17% have heard of them, and 2% know them well.

When taking into account a more scientific approach such as the theories of Barker and Hales or DOHaD, 82% have no knowledge of them with no significant difference between professions (P = 0.4). The same is true with regard to the REACH regulations (Registration, Evaluation and Authorization of Chemicals) and the ECHA (European Chemicals Agency) which are familiar to only 4.5% of respondents and unknown to 78.5% of them, once more with no difference between professions (P = 0.6).

When asking which professions are the most exposed to environmental toxicants, respondents had 75% of correct answers (Table 3). Cashiers, bricklayers, and pet shop employees are the only suggested professions for which the risks are not correctly perceived.

Table 3.

Knowledge about professional exposure to toxicants

Discussion

Exposure to hazardous environmental contaminants is now recognized by the scientific community as an essential preoccupation regarding population health [1]. Perinatal health providers are currently increasingly concerned by the potential exposure of the fetus during the sensitive period of pregnancy [18]. Moreover, a growing interest in the periconceptional period has recently emerged and is considered very important for the health of future generations [2].

Some studies have analyzed the knowledge and awareness of the environment impact on health among perinatal health professionals [14, 15, 17, 19] as well as future mothers [20], but little is known about this concern among professionals working in assisted reproductive technology. However, such professionals would have the opportunity to intervene just before and during the early steps of conception and in this way improve fertility and perhaps ART results. Information given to future parents during this period could not only improve fertility but also stimulate them to change behavior toward a lifestyle with minimal negative environmental impact during childhood. To our knowledge, this is the first study to examine the ART professional’s attitude according to environmental hazards. We have sent a web survey to all the ART professionals with direct patient interaction during the ART treatment: doctors, embryologists, and nurses. This survey was carried out in all French-speaking ART centers in Belgium.

As 67% responded, our web questionnaire provides a representative assessment of ART professionals in French-speaking Belgium, with similar response rate regardless of gender and profession (doctors, embryologists, and nurses). This profile of response rate differs from certain studies concerning practices of perinatal health professionals where midwives were more represented [14]. This response rate is also higher than the 11 to 30% observed in the literature on this topic [14, 15, 17, 19]. A possible explanation for this unusually high response rate for an anonymous web survey is probably that it is a specific targeted population, interviewed in a professional context with the agreement and sometimes even the encouragement of their department head.

The main result about the attention given to environmental health is that 56.5% of ART professional providers never or very rarely tackle the question of hazard exposure. The reasons are mainly (63%) because of a lack of knowledge and for 20.5% because they cannot suggest solutions to the patients. Ninety-two percent asked for more training in this field in order to be able to correctly inform patient on this topic However, 90% of them think that it is a useful approach, while a tenth of the participants are reluctant to this approach because they consider that there is a current lack of EBM data.

Irrespectively of countries and cultures surveys on perinatal professionals, more than 80% agree that recommendations regarding exposure to environmental toxicants are required during their medical care [14, 15, 19].

With 43% of professionals addressing the issue of environmental contaminants and 33% routinely during every initial consultation, it seems that the ART providers are a little more proactive than perinatal professionals. Indeed, Sunyach et al. [14] reported systematic interventions in 16% of the cases and occasional interventions in 41% of the cases. Marie et al. [19] reported that there were interventions fluctuating from 9.2 to 38.5% depending on the pollutant. Same comparisons with North American colleagues even in another cultural context draw comparable conclusions. Among 2514 obstetricians surveyed, 20% routinely asked about environmental exposures, and 50% rarely take an environmental health history among pregnant women in the USA [15].

Nevertheless, in both professional spheres and both continents, the majority of workers (56 to 70%) state that the scarcity of knowledge is the main obstacle to the implementation of this approach. The absence of a solution to offer is an argument twice as important in ART in comparison with perinatal professionals. The fear of the reaction of patients, in the other hand, is almost nonexistent in ART (1.5%), while it discourages 10% of French perinatal professionals to act [14]. Forty-five percent of North American obstetricians disagree that environmental counseling would cause needless anxiety for patients [15]. Only 4.4% of Canadian professionals including nurses (99) and physicians (36) consider patient reaction as a barriers to intervene in Williamson’s study [17]. Lack of evidence about the absolute and relative risk to patients from environmental exposures emerges as a major factor for American obstetricians [15], while this argument concerned only 10% of ART practitioners and 12% of Canadian nurses and physicians surveyed [17]. Moreover, insufficient time constitute a barrier for 62% of Canadian professionals and on the opposite concern only 5.5% of the ART providers. Lack and need for tools to take actions to prevent harmful exposures are also underlined among North American colleagues [17].

The analysis of the differences concerning the professional function in the ART team highlights a greater lack of knowledge for nurses and a lower interest in the environmental question among biologists. This is probably explained by the difference of their training courses program and the difference in patient relationships for these two professions. The small number of studies in human embryology demonstrating correlations between environmental pollutants and specific impact on embryo development may also contribute to this attitude among biologists. Canadians found in their group of physicians and nurses concerned by perinatal care that nurses are more likely concerned by environmental health issue than physicians [17]. Such differences between workers were not significant in our survey.

The level of knowledge of ART professionals is relatively identical to those observed for French perinatal health professionals with a rate of correct and unknown answers of respectively 56% and 36%. We were unable to identify any specific topic around environmental toxicants specifically well-known by ART professionals. However, it was surprising to observe a score of knowledge so low for the food sphere especially with the current existing recommendations and scientific data [16, 21]. Indeed, our questionnaire included two specific questions about the benefit of organic food and the harm of potential fish containing heavy metals and polychlorinated biphenyl (PCB). Despite scientific data based on large cohort studies for organic food [21] and national recommendations for fish consumptions [16], the percentage of correct answers of ART professionals were respectively as low as 21 and 31%. Sunyach et al. underlined also this topic as the less mastered one in their survey among midwives, nurses, and physicians [14]. When information received by pregnant women are analyzed, 39% of them seems to know that toxic agents may be present in nonorganic food. Nevertheless, this information was provided by professionals only for 38% of them [20].

However, the ART professionals have a deeper understanding for the harmful effect of professional activities.

Finally, we underline the lack of knowledge of existing tools, as leaflets and web sites, for 81% of responders and the lack of knowledge about the current regulations for 78% of them.

They all agree to the need for more information for health professionals in the field of environmental health. They ask for continuing education provided by scientific society (69%) or even provide website-type tools for professionals and patients (45%). Many modes of assistances are also identified as helpful for healthcare providers in the Canadian study as online information resources, webinars, and training sessions [17]. French studies emphasize the fact that professionals preferentially use data from scientific literatures to improve their level of knowledge [14] in accordance with 75% of American obstetricians who used ACOG (American Congress of Obstetricians and gynecologists) as primary source of information and guidance [15].

The strength of this prospective study is its large representativeness according to the high response rate and its homogeneity among the different types of professional providers in ART. The structure of the survey with clear and simple questions enables us to draw clear and homogeneous conclusions. It also allows us to highlight the involvement, knowledge, and needs according to the different professionals of ART.

The weakness of this work is the small sample size, which represents only a small part of the ART world. The wording and content of the questions exploring knowledge may have influenced the answers. Binary responses (true/wrong/unknown) may limit nuances and do not allow to establish scores but only percentages.

The studies currently available in the population of Western European culture agree that there is a deficiency concerning the information received by pregnant patient given to them by health professionals. Chabert et al. [20] demonstrated in a survey conducted among patients hospitalized in postnatal unit that only 30% of patients were informed of the potential risks of reprotoxic agents encountered in domestic life (excluding occupational risk and addictions). Patients with a higher level of education were better informed and received this information mainly from the media and not from health professionals. These findings have led some countries to set up “general public” awareness campaigns [20] and training educational programs for professionals [14].

Infertility affects one in six patients, which limits the impact of ART centers to provide information to the general population about preconception health and action against environmental hazards. However, the place of ART before conception makes it an ideal entry point for this prevention in perinatality.

The increasingly evidence on the influence of environmental toxins on fertility [22] constitute an additional argument to integrate these recommendations during the fertility assessment in order to try to optimize the results obtained by ART treatment.

This study reinforces the previous observations which highlight the importance of the concepts of environmental health in the initial and continuous training of health professional [23]. Moreover, this survey supports further emphasis on knowledge building of all professions involved in ART, as well as scientific based specific changes to recommend to patients.

Authors’ contributions

JV: conceived and designed the experiments, realized the web questionnaire, and contributes to the analyses of data and to the statistical analyses.

AD: conceived, designed, and performed the experiments; analyzed and interpreted the data; and wrote the paper.

Data availability

Crude data of web survey available on request in French.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approvals

Authorization to conduct the study given by the local ethics committee in accordance with the new European regulations regarding the protection of personal data, from May 2018 (RGPD) received on April 10, 2019.

Consent to participate

The study is an anonymous survey of a target group of professionals involved in the ART process before conception, and an email requesting participation in a study constitutes the informed consent.