lable at ScienceDirect

European Journal of Oncology Nursing 18 (2014) 201e205

Contents lists avai

European Journal of Oncology Nursing

journal homepage: www.elsevier .com/locate/ejon

Knowledge, attitudes and practices of physicians and nurses regardingthe link between IVF treatments and breast cancer

Ilana Kadmon a,b,*, Yelena Goldin c, Yuval Bdolah d, Morshid Farhat d,Michal Liebergall-Wischnitzer a,b

aHenrietta Szold School of Nursing, IsraelbHadassah/Hebrew University Medical Center, Hadassah Hospital, Kiryat Hadassah POB 12000, Jerusalem, IsraelcClalit Health Services, Kiryat Moshe, Jerusalem, IsraeldReproductive Endocrinology Division, Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Mount Scopus, KiryatHadassah POB 12000, Jerusalem, Israel

Keywords:IVFBreast cancerFertility nursingrisk assessmentClinical breast exam

* Corresponding author. Henrietta Szold HadassahNursing, P.O.B 12000, Jerusalem 91120, Israel. Tel.: þ6439020.

E-mail addresses: ikadmon@hadassah.org.il (I. Korg.il (Y. Bdolah).

1462-3889/$ e see front matter � 2013 Elsevier Ltd.http://dx.doi.org/10.1016/j.ejon.2013.10.009

a b s t r a c t

Purpose: The ovarian stimulating hormones used in In-Vitro Fertilization may increase the incidence ofbreast cancer. Little research has been conducted to ascertain health professionals’ knowledge or prac-tices regarding this possible connection and if they communicate this risk to their patients. This studydescribed the knowledge, attitudes and practices of doctors and nurses regarding the causative linkbetween In-Vitro Fertilization treatments and breast cancer, and to determine if these health pro-fessionals were assessing or communicating this possible risk to their patients.Method: Seventy gynecologists and nurses who worked in fertility clinics, had at least one year ofexperience in fertility and were literate in Hebrew were asked to complete the questionnaires. Ten clinicsaround the country were contacted and the questionnaires were distributed and collected on the sameday.Results: 35 Nurses and 35 gynecologists completed the survey. Although the majority of the physicians(68%) and nurses (69%) thought that there was a possible connection between the hormonal treatment ofIVF and breast cancer, physicians were significantly more likely to inform their patients about theconnection than were nurses.Conclusions: There is a gap between the attitudes and practices of both physicians and nurses incommunicating possible cancer risk to IVF clients. It would be beneficial to create a standardized riskcommunication protocol that would include information and guidelines for practice. More research mustbe conducted in this area, as there is almost no data on possible maternal risk from IVF treatment.

� 2013 Elsevier Ltd. All rights reserved.

Introduction

In-Vitro Fertilization (IVF) is a common infertility treatmentthroughout theworld, and it has been increasing in popularity since1978. One in every 50 births in Sweden,1 in 60 in Australia, and 1 inevery 80e100 births in the United States are the result of IVF. In2003, more than 100,000 IVF cycles were reported by 399 clinics inthe US, with a live birth rate of more than 48,000 babies (Van

Hebrew University School of972 2 6777757; fax: þ972 2

admon), ybdolah@hadassah.

All rights reserved.

Voorhis, 2007). In 2012, there were an estimated 5 million infantsborn through IVF technology (ESHRE, 2013).

In relation to the population size and the number of IVF treat-ments performed, Israel is the leader, out of 48 counties, in thenumber of IVF/ICSI cycles per million people per year (Collins,2002). In contrast to other Western European countries, IVF iscovered in Israel by the national health insurance up to the age of45 and for two live births (Simonstein, 2010), which greatly ex-pands its availability to the infertile population.

Infertility treatments include ovarian stimulating hormonalmedications that may have potential negative side effects,including the development of cancer due to inter-cell modificationscaused by the treatments. There is little discussion, however, as toif, how and when physicians or any health professional shoulddiscuss this particular risk, or other maternal health risks, with the

I. Kadmon et al. / European Journal of Oncology Nursing 18 (2014) 201e205202

patient, and whether the patient should be informed of thesepossible risks. Pre-Artificial Reproductive Technology (ART) riskassessment, both psychological and the risk for developing breastcancer, has been poorly studied, yet due to the growing number ofIVF cycles performed each year, further research into its imple-mentation may be recommended.

Background

The influence of female hormones on the etiology and thedevelopment of breast cancer are well known (Lipworth, 1995).Early menstruation and late menopause both are related to longterm exposure to high levels of circulating endogens and to the riskfor developing breast cancer (Bernstein, 2002; Borini and Rebellato,2008). The use of ecogene hormones during fertility treatmentsraises questions regarding their usage and the risk of developingbreast cancer (Healy and Venn, 2003; Kanakas and Mantzavinos,2006; Katz et al., 2008). In a study conducted in the US involvingmore than 12,000 women who had undergone IVF treatment be-tween 1965 and 1988 with Clomephene Citrate and gonado-trophines, there was a significant increase of breast cancer foundamong these women as compared to the general population(Brinton et al., 2005, 2004). On the other hand, Burkman et al.(2003) retrospectively examined 4575 women with breast cancer,as compared to a control group, and found that the drugs used forIVF did not cause a higher risk for breast cancer. Similarly, Bragaet al. (1996), studying women with fertility problems, alsodemonstrated that although hormonal treatment for these womendid raise their risk for developing breast cancer, it was not statis-tically significant. A Finnish study examined a cohort of 9175women who purchased IVF medications and followed thesewomen for a period of two years. They concluded that the generalcancer risk of hormonal related cancers in women was notincreased by IVF treatment (Yli-Kuha et al., 2012). In 2013, Li andcolleagues reported a meta-analysis of eight cohort studies andthey concluded that there is no significant association between IVFand cancer risk (Li et al., 2013). Brinton et al., also in 2013, in theirstudy of 87,000 women who went through IVF and looking at theiroverall cancer risk, also found no significant relationship betweenIVF and the risk for breast, ovarian and endometrial cancers(Brinton et al., 2013). Although they concurred that, in the generalpopulation, there was no significant additional risk of breast cancer,Katz et al.’s (2008) large cohort study did find that over the age of30 there is increased breast cancer risk while Stewart et al. (2012)study of 21,025 women also found significant breast cancer riskfor women under 24 years of age.

To date, the most current research suggests that there is not alink between IVF treatment and future development of breastcancer.

Doctors and nurses knowledge, attitudes and practice, regarding IVFand breast cancer

Very little research has been conducted as to how health pro-fessionals incorporate Evidence based practice (EBP) into their owndaily clinical activity, or how they feel when EBP protocols areimposed upon them (Graham, 1998). In addition, little is knownabout the congruence between health professionals’ attitudes andactual practice toward many routine procedures. For this study, noarticles could be located describing health professionals’ attitudestoward a possible connection between IVF and breast cancer, or anyother possible maternal risk of IVF treatment at all.

Ascertaining physician or nurse attitude and practice towardother protocols was also difficult. For the few studies that wereconducted, anonymous questionnaires requesting informationabout knowledge, practice and attitudes were sent to large groups

of physicians (Hunter et al., 1998; Graham et al., 1998; Walter andBritten, 2002; Preissig and Rigby, 2010). It is evident from thosestudies and additional theoretical reviews that there is often aconflict between institutional protocol and provider implementa-tion, but perhaps more importantly between provider attitude andactual practice (Aarons, 2005).

The study

Aims

The purpose of this study was to describe the knowledge, atti-tudes and practices of doctors and nurses regarding the causativelink between IVF treatments and breast cancer, and to elucidate therelationship between their knowledge, attitudes and practicesregarding this link and sociodemographic variables.

Design

This is a cross-sectional correlational study with conveniencesampling of physician and nurse employees of fertility clinicsthroughout Israel.

Sample/participants

The sample included nurses and gynecologists who wereemployed in IVF clinics in 10 hospitals in Israel. Gynecologists andnurses who had worked in an IVF clinic, for at least one year andwere literate in Hebrew were eligible to participate in this study.

The initial suggested sample size was 128 participants, dividedequally between nurses and physicians, in order to reach a power of80% with p ¼ 0.05, and assuming a medium effect size. However,only 70 participants were surveyed, due to logistic limitations.

Data collection

As there was no instrument found in the literature created toascertain physician or nurse attitudes toward IVF protocol andpossible risks, both physician and nurse questionnaires weredesigned by the one of the researchers (Y.G) after collaboratingwith IVF, breast cancer and methodological experts. A total of 19questions were divided into three sections: knowledge, attitudesand practices. As there is no gold standard for validation, expertvalidation by two physicians who run fertility centers, three expertIVF nurses and two clinical breast care nurse specialists wasreceived. After questionnaire review and modification, the presentversions were accepted. A sociodemographic questionnaire wasalso included. A pilot study was then conducted to further validatethe questionnaires.

Ethical consideration

Approval was received by the ethics review committee of thesponsoring hospital. Participants signed a consent form prior tocompleting the questionnaire and no identifying information wascollected, keeping the responses anonymous.

Data analysis

The statistical analysis included descriptive statistics, Indepen-dent t-test for continuous variables and Pearsons correlation forcategorical variables. Factor analysis using the Manova was alsoconducted to analyze possible significant differences betweenphysician and nurse responses.

I. Kadmon et al. / European Journal of Oncology Nursing 18 (2014) 201e205 203

Validity and reliability

The Physician IVF KAP had a Cronbach’s a of 0.80 and the NurseIVF KAP a Cronbach’s a of 0.69.

Results

This study included 70 participants, of them 35 (50%) werenurses and 35 (50%) were physicians, all employed in IVF clinicsthroughout Israel. Twenty-three (33%) were men and the rest werewomen. The average age of each participant was 46 (SD ¼ 8.74),ranging from 27 to 67 years of age. Most of the participants (90%)were married and the rest were divorced, single or widowed. Allthe participants had at least one child. Forty seven percent of themwere senior gynecologists and two were residents. The averagetime of employment in an IVF clinic was nine years, ranging fromthree to 39 years (Table 1).

Knowledge, attitudes and practice

Most physicians and nurses (46, 67%) felt a possible connectionexists between IVF and breast cancer. Fourteen (41%) of the phy-sicians and fourteen (43%) of the nurses answered that a definitiveconnection between age of the patient and breast cancer incidencehad not been proven (see Table 2).

Fifteen (44%) of the physicians and thirteen (37%) of the nursesfelt that the age limit of 45 should be maintained and not changedbut that women over 40 should receive information about possibleincreased risk of future breast cancer incidence. Sixteen (50%)

Table 1Sociodemographic variables.

Variable Category Frequency % Response

Gender Female 47 67Male 23 33

Marital status Single 1 1Married 63 90Divorced 5 7Widowed 1 1

Children Yes 70 100No e e

Profession Nurse 35 50Doctor 35 50

Degree Certified Nurse 10 14BSc. 19 27MSc. 6 9MD 35 50

Professional status Nurse 35 50Resident 33 47Physician 2 3

Working status Full-time 31 44Part-time 39 56

Country of Origin Israel 45 66Former U.S.S.R 16 24Europe 6 9Other 1 1

Religion Jewish 65 93Christian 2 3Muslim 3 4

Religious affinity Ultra Orthodox/Very Religious 1 1Religious 17 24Traditional 14 20Secular 38 54

physicians and twenty-six (74%) nurses felt that the medicalestablishment should increase the level of awareness of a possibleconnection between IVF and breast cancer, as it is the public’s rightto know. Thirty-three (97%) of physicians and thirty-two (91%) ofnurses felt that patient’s request for minimal hormone exposureshould be taken into account when deciding whether to conducttreatment, together with a clinical explanation as to possibletreatment failure. Ten (29%) of the physicians and twenty-one (60%)of the nurses feel that limiting the number of IVF cycles should bedetermined by the number of risk factors that the patient has todevelop breast cancer. The majority of physicians (67%) and nurses(69%) felt that the practitioner should present the possibleconnection to the patient. The overwhelming majority of the par-ticipants, 74% of the physicians and 69% of the nurses felt that thisrisk information should be added to the informed consent form inthe IVF clinic.

We did not find significant differences between doctors andnurses in any of the 19 questions, and we did not find significantdifferences in the 19 questions between various demographic sub-groups. Therefore, we performed a factor analysis of the 19 ques-tions that resulted in four scales which explained 68.5% of thevariance: treatment risk and risk management; breast examina-tion; providing the patient with relevant risk information;consideration of the patient’s needs. A total of 13 variables hadsignificant loadings onto one of the four factors. In a comparison ofphysician and nurse scores using these four scales (using Manova),a significant difference was found between doctors and nurses inthe practice of giving information: physicians tend to inform theclients about the connection between IVF treatment and breastcancer more than nurses do (F (1, 65) ¼ 4.301; p ¼ 0.042).

Sixteen (47%) of the physicians and twelve (34.3%) of the nursessaid theywould discuss the possible connection between hormonaltreatment and breast cancer only if the woman presented with abreast cancer risk factor and seven (21%) of the physicians and nine(25.7%) of the nurses said they would only discuss the possibleconnection if the patient brought up the issue. In regards toproviding information on the possible connection, the majority ofphysicians (18, or 56%) and nurses (14, or 56%) would tell the pa-tient that it is likely that there is a connection between hormonaltreatment and breast cancer.

Thirteen (38%) of the physicians said they always conduct clin-ical breast exams (CBE), by themselves, before proceeding with anIVF treatment, compared to thirteen (38%) of the physician partic-ipants that said they never conduct CBE prior to treatment. Twenty(59%) of the physicians reported that they always refer the patientto a surgeon for CBE. In Israel, it is the norm for breast surgeons toconduct CBE instead of the gynecologist (Israeli Ministry of Health,2005). The nurses were asked if the physicians in their wardsconduct CBE on new patients. Thirteen (37%) responded that thephysician always conducts a CBE and 12 (34%) said the physiciannever conducts a CBE. Twenty (59%) of the physicians stated thatthey always refer awoman to receive a CBE by a surgeon prior to theIVF treatment. When the nurses were asked, they responded thateighteen (51%) of the physicians always refer the patient to a sur-geon to receive a CBE prior to treatment.

Twenty-one (61%) of the physicians said they would notbegin treatment without the results of a breast exam and fifteen(43%) of the nurses concurred. Seventy one percent of bothphysicians and nurses said that there was an institutional pro-tocol in place requiring that a breast exam be conducted prior toinitiating IVF treatment. There was no statistically significantconnection between attitudes and any of the sociodemographicvariables, age, education, age at immigration, years of experi-ence, or years working in an IVF clinic for neither nurses norphysicians.

I. Kadmon et al. / European Journal of Oncology Nursing 18 (2014) 201e205204

Discussion

The survey was based on the model of the theory of reasonedaction, which suggests that the attitude toward a particular objector concept influences eventual behavior, but it is not the onlypredictor and is influenced by a spectrum of contextually basedvariables (Ajzen and Fishbein, 1977; Bagozzi, 1992). In this study,both physicians and nurses felt there was potential risk for thepatient but did not actually change their behavior with the patientto address her of this risk.

The majority of physicians and nurses felt that there was aconnection between IVF and breast cancer, despite the growingbody of evidence that suggests that there is no connection betweenthe two. They also support, in part, their current institutional pro-tocol that requires the physician to conduct a clinical breast examor at least refer a woman to an exam prior to initiating the treat-ment. However, neither the physician nor the nurse is raising theissue of possible risk with the patient herself.

Approximately 40% of doctors and nurses answered that there isno definite connection between age and breast cancer incidence.Although there is a large body of evidence to suggest that IVF doesnot increase breast cancer risk generally, there is research sup-porting that IVF does increase risk for women beginning IVFtreatments after the age of 30 (Katz et al., 2008) and prior to age 24(Stewart et al., 2012). This implies that women undergoing IVFtreatment at an older age may be at increased risk for developingbreast cancer.

It was interesting to note that both doctors and nurses thoughtthat it is important to add the information of the possibleconnection between IVF and breast cancer to the informed consentbefore the treatment initiation (the current form does not includesuch information). There seems to be a gap between the profes-sional attitudes toward the issue and actual practice. Although themajority of physicians and nurses stated that they knew there wasan institutional protocol for CBE and that they themselves eitherexamined the patient or had the woman physically examined forbreast malignancies prior to the treatment, most practitioners didnot discuss possible increased breast cancer risk with the patient. Itwas not part of the provider patient dialogue at all. This raisesinteresting questions as to how much providers discuss risk withtheir patients in general even if the provider believes there to be arisk.

Communicating possible risk of a procedure to the patient canbe challenging for the health professional, especially in a situationwhere the objective risk is unclear and the subjective outcome forthe patient is also uncertain (Bogardus et al., 1999). However, thehealth professional may have an obligation to insure that the pa-tient understands all of the possible risks and benefits of theprocedure before deciding to commit to the treatment (Bogarduset al., 1999). Health professional assisted decision-making shouldhelp “minimize the chances of undesired consequences accordingto the best possible scientific evidence” (O’Connor et al., 2003, p.736). Segev et al. (2011) proposed a pre-ART medical assessmentto identify possible risk factors for maternal morbidity duringpregnancy and immediately post partum for women over 40(2011). Yet breast cancer may not be the only possible risk forwomen undergoing IVF procedures. Research has suggested apossible connection with endometrial and ovarian cancers(Calderon-Margalit et al., 2009).

Perhaps an additional risk communication component shouldbe added for non-pregnancy related morbidity potentially associ-ated with IVF treatment. Although some discussion about a stan-dardized approach for risk disclosure has been described in theliterature (Bogardus et al., 1999), there is no current dialogue aboutstandardized maternal risk disclosure for IVF treatment.

Although there has been concern among researchers and prac-titioners about the possible connection between IVF treatment andfuture breast cancer, an abundance of data asserts the lack ofconnection. This study suggests that nurses and physicians are stillconcerned about their patients’ risk enough to implement pro-tocols that moderately assess breast cancer risk before treating thepatient; however the patient is not yet part of the risk communi-cation dialogue. Perhaps review and standardization of protocols issuggested, along with protocols for discussion of maternal risk, ingeneral, in regards to fertility treatment.

Limitations

� No questionnaires were found in the literature regarding theknowledge, attitudes and practices assessment of physiciansand nurses regarding possible connection between IVF treat-ments and breast cancer. Therefore, the validity and reliability ofthe questionnaire was tested only in the specific studypopulation.

� The study involved a convenience sample of doctors and nurseswho were specifically approached by the researcher, withminimal diversity in culture, education or age.

Conclusions and implication for practice

It will be beneficial for physicians and nurses to have a stan-dardized pre ART risk assessment protocol, which would include astandardized risk discussion with the patient. Given the currentresearch, it is advisable that every patient would sign informedconsent that would include relevant information of the possibleconnection between IVF treatments and breast cancer. In addition,nurses working in fertility clinics are in an ideal position to engagepatients in a discussion of risk assessment so that the patient maymake a truly informed decision about IVF treatments.

Conflict of interest statement

None declared.

Role of funding source

No external sources of funding.

Acknowledgments

The authors would like to thank Aviva Yoselis of Israel HealthConsulting for her editorial assistance in preparing this manuscript.

Appendix A. Supplementary material

Supplementary material associated with this article can befound, in the online version, at http://dx.doi.org/10.1016/j.ejon.2013.10.009.

References

Aarons, G.A., 2005. Measuring provider attitudes toward evidence-based practice:consideration of organizational context and individual differences. Child Ado-lesc. Psychiatr. Clin. N. Am. 14, 255e271.

Ajzen, I., Fishbein, M., 1977. Attitude-behavior relations: a theoretical analysis andreview of empirical research. Psychol. Bull. 84, 888e918.

Bagozzi, R.P., 1992. The self-regulation of attitudes, intentions, and behavior. Psy-chol. Q. 55, 178e204.

Bernstein, L., 2002. Epidemiology of endocrine-related risk factors for breast cancer.J. Mammary Gland Biol. Neoplasia 7, 3e15.

I. Kadmon et al. / European Journal of Oncology Nursing 18 (2014) 201e205 205

Bogardus Jr., S.T., Holmboe, E., Jekel, J.F., 1999. Perils, pitfalls, and possibilities intalking about medical risk. J. Am. Med. Assoc. 281, 37e41.

Borini, A., Rebellato, E., 2008. Focus on breast and ovarian cancer. Placenta 29, 184e190.

Braga, C., Negri, E., La Vecchia, C., Parazzini, F., Dal Maso, L., Franceschi, S., 1996.Fertility treatment and risk of breast cancer. Hum. Reprod. 11, 300e303.

Brinton, L.A., Moghissi, K.S., Scoccia, B., Westhoff, C.L., Lamb, E.J., 2005. Ovulationinduction and cancer risk. Fertil. Steril. 83, 261e274.

Brinton, L.A., Scoccia, B., Moghissi, K.S., Westhoff, C.L., Althuis, M.D., Mabie, J.E.,et al., 2004. Breast cancer risk associated with ovulation-stimulating drugs.Hum. Reprod. 19, 2005e2013.

Brinton, L.A., Trabert, B., Shalev, V., Lunenfeld, E., Sella, T., Chodick, G., 2013. In vitrofertilization and risk of breast and gynecologic cancers: a retrospective cohortstudy within the Israeli Maccabi Healthcare Services. Fertil. Steril. 99, 1189e1196.

Burkman, R.T., Tang, M.T., Malone, K.E., Marchbanks, P.A., McDonald, J.A.,Folger, S.G., et al., 2003. Infertility drugs and the risk of breast cancer: findingsfrom the National Institute of Child Health and Human Development Women’sContraceptive and Reproductive Experiences Study. Fertil. Steril. 79, 844e851.

Calderon-Margalit, R., Friedlander, Y., Yanetz, R., Kleinhaus, K., Perrin, M.C.,Manor, O., et al., 2009. Cancer risk after exposure to treatments for ovulationinduction. Am. J. Epidemiol. 169, 365e375.

Collins, J., 2002. An international survey of the health economics of IVF and ICSI.Hum. Reprod. Update 8, 265e277.

ESHRE (European Society of Human Reproduction and Embryology) (2013, July 1).ART fact sheet. Retrieved from: http://www.eshre.eu/Guidelines-and-Legal/ART-fact-sheet.aspx.

Graham, I., Stiell, I., Laupacis, A., O’Connor, A., Wells, G., 1998. Emergency physicians’attitudes toward and use of clinical decision rules for radiography. Acad. Emerg.Med. 5, 134e140.

Graham, J., 1998. Perspectives. AHCPR’s evidence-based centers: will their findingsguide clinical practice? Med. Health 52, 1e4.

Healy, D.L., Venn, A., 2003. Infertility medications and the risk of breast cancer.Fertil. Steril. 79, 852e854.

Hunter, A., Wright, P., Cappelli, M., Kasaboski, A., Surh, L., 1998. Physician knowledgeand attitudes towards molecular genetic (DNA) testing of their patients. Clin.Genet. 53, 447e455.

Israeli Ministry of Health, 2005. Health Ministry Report and Protocol Recommen-dations: Breast Cancer Prevention and Early Discovery. Retrieved from http://www.health.gov.il/hozer/mk25_2005.pdf.

Kanakas, N., Mantzavinos, T., 2006. Fertility drugs and gynecologic cancer. Ann. N. Y.Acad. Sci. 1092, 265e278.

Katz, D., Paltiel, O., Peretz, T., Revel, A., Sharon, N., Maly, B., et al., 2008. BeginningIVF treatments after age 30 increases the risk of breast cancer: results of a caseecontrol study. Breast J. 14, 517e522.

Li, L.L., Zhou, J., Qian, X.J., Chen, Y.D., 2013. Meta-analysis on the possible associationbetween in vitro fertilization and cancer risk. Int. J. Gynecol. Cancer 23, 16e24.

Lipworth, L., 1995. Epidemiology of breast cancer. Eur. J. Cancer Prev. 4, 7e30.O’Connor, A.M., Légaré, F., Stacey, D., 2003. Risk communication in practice: the

contribution of decision aids. BMJ 327, 736e740.Preissig, C.M., Rigby, M.R., 2010. A disparity between physician attitudes and

practice regarding hyperglycemia in pediatric intensive care units in the UnitedStates: a survey on actual practice habits. Crit. Care 14, R11. Retrieved from:http://ccforum.com/content/14/1/R11 (01.07.13).

Segev, Y., Riskin-Mashiah, S., Lavie, O., Auslender, R., 2011. Assisted reproductivetechnologies: medical safety issues in the older woman. J. Women’s Health(Larchmt) 20, 853e861.

Simonstein, F., 2010. IVF policies with emphasis on Israeli practices. Health Policy97, 202e208.

Stewart, L.M., Holman, C.D., Hart, R., Bulsara, M.K., Preen, D.B., Finn, J.C., 2012.In vitro fertilization and breast cancer: is there cause for concern? Fertil. Steril.98, 334e340.

Van Voorhis, B.J., 2007. Clinical practice. In vitro fertilization. N. Engl. J. Med. 356,379e386.

Walter, F.M., Britten, N., 2002. Patients’ understanding of risk: a qualitative study ofdecision-making about the menopause and hormone replacement therapy ingeneral practice. Fam. Pract. 19, 579e586.

Yli-Kuha, A.N., Gissler, M., Klemetti, R., Luoto, R., Hemminki, E., 2012. Cancermorbidity in a cohort of 9175 Finnish women treated for infertility. Hum.Reprod. 27, 1149e1155.