Introduction
More countries are providing access to assisted reproductive technology (ART) within their healthcare systems, and an increasing number of children are being conceived through ART. These technologies include in vitro fertilization and embryo transfer (IVF-ET), intracytoplasmic sperm injection (ICSI) and gamete intrafallopian transfer (GIFT). These technologies are treatments or procedures that include the in vitro handling of human oocytes and sperm or embryos for the purpose of establishing pregnancy. In IVF, eggs are removed from a woman's ovary and fertilized with sperm outside of the body. The fresh or frozen embryo is transferred to the woman's uterus. In ICSI, a single sperm is injected directly into each egg in a laboratory procedure. Finally, GIFT is a process where the eggs and sperm are mixed and then placed in the woman's fallopian tubes to establish pregnancy. Among 52 countries, Japan reported the largest number of ART cycles in which follicles were punctured and aspirated.1 The percentage of total live births resulting from ART in Japan has increased from 0.5% in 1996 to 5.5% in 2016.2
Various studies have described experiences specific to pregnancy after ART. Women who become pregnant after infertility were reported to have greater specific anxiety, such as fetal survival and normality3-6 and other complex issues.5,7 In early pregnancy, these women reported experiencing paradoxical feelings such as joy and fear, or hope and uncertainty,8,9 and had difficulty perceiving themselves as pregnant women.10,11 The transition to motherhood generally begins when a woman finds out she is pregnant, and represents a process of active engagement.12 However, following ART, pregnant women must go through role acquisition and adjustment, while potentially experiencing anticipatory anxiety about the potential loss of a pregnancy or fetus, and feeling ambivalent over the transition from an “infertile” identity to a “pregnant” identity.5,11,13,14 Women who have undergone ART may also delay developing an attachment to the fetus and preparing for the maternal role.15-17 Bernstein13 identified various factors that contribute to mothering disturbances after infertility, including a lack of appropriate role models for mothering after infertility, delayed attachment to the baby, and the disparity between the image and actual experience of motherhood. During pregnancy, women who have undergone ART face unique challenges in terms of their transition to motherhood.
A quantitative systematic review by Hammarberg et al.18 explored the psychological and social aspects of pregnancy after assisted conception. This review concluded that after ART, women had higher anxiety about the survival of the fetus and more early parenting difficulties compared with women who spontaneously conceived. However, evidence regarding women's emotional adjustment to pregnancy after ART is inconclusive, with some studies suggesting it is problematic and others indicating there are self-protective delays in believing in the pregnancy,11,13,14 forming an emotional attachment to the fetus,11,17 and preparing for life with a baby.11 Another quantitative systematic review by Gourounti19 revealed that women who conceived after IVF had greater pregnancy-specific anxiety, lower quality of life, the same or lower levels of depressive symptomatology, the same level of self-esteem, more positive attitudes toward pregnancy demands, and higher levels of maternal-fetal attachment compared with women who spontaneously conceived. However, methodological limitations and confounding factors may explain the inconsistencies in previous findings regarding the impact of ART. In particular, previous systematic reviews only included quantitative studies. A narrative review that included both qualitative and quantitative studies indicated that women have higher levels of anxiety in pregnancy after infertility treatment, and may experience some difficulties in the transition to parenthood, leading to perinatal morbidity.20 Other qualitative studies suggested that the process of assuming a maternal identity during the transition to motherhood may be qualitatively different for pregnant women who conceived through ART.11,13,14,16,21 Women who conceived via ART may also require more support from nurses/midwives to address anxiety during pregnancy and allow them to express any negative feelings, review their infertility experiences and help them prepare for parenthood.21-23 Understanding the context and complexity of emotional adaptation to pregnancy following ART is important for healthcare professionals working with these women. In particular, healthcare professionals need to remain sensitive to the special path to parenthood for women after ART16 and their paradoxical care needs during pregnancy.24 A qualitative systematic review can provide the best available evidence to inform development of nursing interventions to meet the needs of this population.
A preliminary search of PROSPERO, the JBI Database of Systematic Reviews and Implementation Reports, the Cochrane Database of Systematic Reviews, CINAHL and MEDLINE was conducted. This search identified two quantitative systematic reviews that addressed psychosocial aspects of pregnancy after ART.18,19 However, no current or underway qualitative systematic reviews on experiences of transition to motherhood during pregnancy among women who conceived through ART were identified, other than those focused on prenatal care by midwives.25 In addition, previous systematic reviews only covered literature published in the English language,18,19 and although they included East Asian studies, Japanese literature was excluded. In Japan, nursing researchers often publish qualitative research findings in the Japanese language to disseminate implications from narratives to clinical practice. The increasing practice of ART in Japan over the previous two decades has produced a growing number of Japanese studies regarding pregnancy after infertility.9,11,14,23 Findings from these studies have not been reflected in previous systematic reviews. We conducted a preliminary search of Ichushi-Web, a bibliographic database containing biomedical journals and other serial publications published in Japan, and no qualitative systematic reviews addressed this topic. Therefore, this systematic review will include studies published in English or Japanese to provide cumulative insights, create understanding of the transition to motherhood among pregnant women following ART and guide future research to develop best practice for these women.
This systematic review aims to identify and synthesize the available qualitative evidence related to the experiences of transition to motherhood during pregnancy in women who conceived through ART.
Review question
What are the experiences of transition to motherhood during pregnancy among women who conceived through ART?
Inclusion criteria
Participants
This review will consider studies that explored the experiences of transition to motherhood during pregnancy among women who conceived through ART. In this review, ART includes IVF-ET, ICSI and GIFT. Studies that only focused on intrauterine insemination (IUI) or ovulation induction (OI) will be excluded. These methods are less invasive forms of fertility treatment. Women undergoing OI take medications to stimulate ovaries to produce more eggs, whereas IUI refers to a procedure of inserting prepared sperm into the uterus. Studies including mixed samples in which some women underwent ART and others were treated with IUI or OI will be retained. In addition, this review will only consider studies with the collaboration of adult women (aged ≥20 years), regardless of their marital status, residential area or whether they used donor gametes.
Phenomena of interest
This review will consider studies that described the experiences of transition to motherhood during pregnancy in women who conceived through ART, including perceptions, meanings or experiences of becoming a mother26; psychosocial adaptation in pregnancy; expressed maternal identity; perceived maternal role and behaviors; and bonding with the fetus during pregnancy. Studies where data were collected outside the pregnancy period, and those based on narratives from other people (e.g., pregnant women's mothers, partners, friends, siblings) will be excluded. In addition, we will only include studies in which healthcare professionals (regardless of their sex) collected empirical data. We intend that the qualitative evidence obtained in our review will help healthcare professionals, such as nurses and midwives, improve their care for pregnant women after ART. Our review will also exclude studies that only focused on specific topics, such as disclosure of the use of donor gametes, surrogacy, same-sex parenting, multiple pregnancy, multi-fetal reduction, sex selection, pre-implantation genetic diagnosis, any fetal abnormality, pregnant women with special needs (e.g., spinal injuries, deafness) and secondary infertility.
Context
All primary studies with data collected through interviews and observations will be considered, independent of the location (e.g. healthcare facilities, home visits) where these data were collected.
Types of studies
This review will consider empirical studies that focus on qualitative data including, but not limited to, designs and methods such as phenomenology, grounded theory, ethnography, qualitative description, qualitative content analysis and thematic analysis. Qualitative data from mixed methods studies will also be included. Studies that use statistical reports of results, clinical case reports, historical analysis, review articles, meta-analyses or meta-syntheses, editorials, commentaries, letters, conference abstracts, and studies with no available full text will be excluded.
Over the previous 20 years, ART has become common globally, and ART practice has changed with increasing use of ICSI rather than conventional IVF.1 The first baby in the world resulting from ICSI was born in 1992, and the first in Japan was born in 1994. Therefore, studies published from 1992–2019 in English or Japanese will be considered for this systematic review, as we are currently unable to translate studies published in other languages.
Methods
The proposed systematic review will be conducted in accordance with the JBI methodology for systematic reviews of qualitative evidence.
Search strategy
The search strategy will aim to locate published and unpublished studies. The PICo framework (population, phenomena of interest and context) will be used to identify the search terms in the review question. An initial limited search of MEDLINE (English language) and Ichushi-Web (Japanese language) was conducted, followed by an analysis of text words contained in the titles and abstracts, and index terms used to describe the articles. An example search strategy for MEDLINE is presented in Appendix I. The reference lists of all studies selected for critical appraisal will be screened for additional studies.
Information sources
The databases to be searched for published studies will include: MEDLINE, CINAHL, PsycINFO, ProQuest Health & Medical Collection (limited to literature written in English) and Ichushi-Web (literature written in Japanese). The search for gray literature will include Google Scholar and Open Access Theses and Dissertations (in English), and CiNii and the Institutional Repositories Database, which are Japanese database services that can be searched for academic information from articles, books, journals and dissertations (in Japanese).
Study selection
Following the database searches, all identified citations will be collated and uploaded into EndNote basic (Clarivate Analytics, PA, USA), and duplicates removed. Titles and abstracts will then be screened by two independent reviewers in full, and citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; Joanna Briggs Institute, Adelaide, Australia). The full text of selected citations will be assessed in detail by two independent reviewers against the inclusion criteria. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the systematic review. Any disagreements between the reviewers that arise at each stage of the study selection process will be resolved through discussion, or by a third reviewer. The results of the screening will be reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram.27
Assessment of methodological quality
Eligible studies will be critically appraised by two independent reviewers for methodological quality using the standard JBI Critical Appraisal Checklist for Qualitative Research.28 The reviewers determined that questions 2, 3, 4, 5, and 10 on the critical appraisal checklist are essential for methodological quality. Papers will be excluded if they are rated “no” for any of those questions. Any disagreements relating to methodological quality between the reviewers will be resolved through discussion, or by a third reviewer. Authors of papers will be contacted to request missing or additional data where clarification is required. The results of the critical appraisal will be reported in narrative form and in a table.
Data extraction
Qualitative data will be extracted from papers included in the review using a standardized data extraction tool for qualitative evidence (JBI SUMARI). The extraction will be performed by two independent reviewers. To ensure consistency during the extraction process, the two reviewers will meet to compare the extracted data in a Microsoft Word (Redmond, Washington, USA) document before entry into the JBI SUMARI data extraction form. The extracted data will include specific details about the populations, context, culture, geographical location, study methods and phenomena of interest relevant to the review question and specific objectives. Findings and their illustrations will be extracted and assigned a level of credibility. Findings will be described as “unequivocal” or “credible”, as recommended in the JBI Reviewer's Manual.28 All “unsupported” findings will be excluded from the review. Any disagreements relating to credibility that arise between the reviewers will be resolved through discussion, or by a third reviewer. Findings and their illustrations from literature published in English will be translated into Japanese, and those from literature published in Japanese will be translated into English by two independent translators. Then, reviewers who are familiar with the issue under study will check the translations for equivalent meaning.
Data synthesis
Where possible, qualitative research findings will be pooled using JBI SUMARI with meta-aggregation. This will involve the aggregation or synthesis of findings to generate a set of statements that represent aggregation, through assembling and categorizing these findings based on similarity in meaning. These categories will then be subject to synthesis to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. The categories and synthesized findings will be agreed by discussion among the reviewers to ensure they support the meaning of the translated data. Where textual pooling is not possible, the findings will be presented in narrative form.
Assessing confidence in the findings
The final synthesized findings will be graded according to the ConQual29 approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings. This table will include the major elements of the review and detail how the ConQual score was developed. The table will include the title, population, phenomena of interest and context for the studies included in the review. Each synthesized finding from the review will be presented along with the type of research informing it and a score for dependability, credibility and the overall ConQual score.
Funding
This study was supported by a Grant for Social Welfare Activities from The Mitsubishi Foundation.
Acknowledgments
We thank Dr. Patraporn Tungpunkom, Faculty of Nursing, Chiang Mai University, The Thailand Centre for Evidence Based Health Care: a Joanna Briggs Institute Affiliated Group, for feedback on the draft.
Appendix I: Search strategy for MEDLINE (EBSCOhost)
1 [MH “Pregnant Women”]
2 [MH “women”]
3 expectant AND (mother∗ OR wom∗)
4 [MH “Infertility”]
5 [MH “Reproductive Techniques, Assisted”]
6 assist∗ AND (conceive∗ OR concepti∗ OR reproducti∗)
7 reproducti∗ AND (technic OR technics OR technique OR technology)
8 “in vitro” AND (fertili∗ OR reproducti∗)
9 IVF OR “IVF-ET”
10 (fertility OR infertility) AND treatment∗
11 [MH “Qualitative Research”]
12 qualitative
13 [MH “Grounded theory”]
14 phenomeno∗
15 ethnograph∗
16 “content analysis”
17 “thematic analysis”
18 1 OR 2 OR 3
19 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10
20 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17
21 18 AND 19 AND 20
22 limit 21 to (English language and yr = “1992–Current”)
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