Title: Fertility quality of life (FertiQoL) among Chinese women undergoing frozen embryo
transfer
Version: 2 Date: 03 Feb 2021
Reviewer's report:
The manuscript “Fertility quality of life (FertiQoL) among Chinese women undergoing frozen-
thawed embryo transfer” aimed at assessing quality-of-life for a large group of Chinese women
undergoing frozen embryo transfer. While the data add to the growing literature on poor quality-
of-life for women with infertility, the manuscript requires some clarification and editing prior
to consideration for publication.
Recommendations:
Please number each line of the manuscript so we may provide more directed feedback.
Background:
You cannot comment on IVF success rates as a whole (in the text cite as 30%). This depends on
multiple factors including age of the patient, infertility diagnosis, etc.
Throughout the manuscript and abstract you comment on comparing QOL scoring for women
undergoing frozen embryo transfer to those undergoing fresh embryo transfer. However, this
is a cross-sectional study with no comparator group. The purpose of the study appears simply
to analyze the QOL scores for this patient population. Please make that clear in the manuscript
and abstract. Additionally, please state how this adds to the literature. Are you the first group
to analyze only patients undergoing frozen embryo transfer? Is there a study analyzing patients
undergoing only fresh embryo transfer? Do you have significantly more responses than previous
studies?
Methods:
You also included infertility diagnosis in the basic questionnaire (female vs male vs
unexplained). This should be mentioned.
FPI: please state the minimum and maximum scores for each dimension (social concern,
relationship concern, parenthood score etc) to give context for the scores you list in the results.
STAI: Please explain more clearly that this scoring system assesses “anxiety state” and “anxiety
trait” and what the difference is between those two (you have both listed in results). Please also
explain “reverse scoring”. This appears to simply be a 4-point scoring system but the wording
on reverse scoring is confusing.
The questionnaires with missing data should not be completed with the average scores imputed
as this will skew the data. The data should be run only on the data available with a note on how
many patients were missing data for each field.
Results:
Table 1:
Need unit of measure for monthly household income
Please explain “Fertility Situation” - is this parity?
Table 2:
Need to include units of measure for duration of infertility/duration of treatment (years?)
Cause of infertility should state “female-factor” “male-factor” “combined male and female-
factor” and “unexplained” or “idiopathic”
By history of reproductive technology, do you mean IVF or is oral ovulation induction included
in this? This should be explained in the Methods section.
What do you mean by Subject Treatment? This should be explained in the Methods section.
What do you mean by Gynecologic History? This should be explained in the Methods section.
Scores of scales:
Please cite the resource used for the scores for the general female population. Additionally, this
information should have been introduced in the background (what do we know already about
anxiety in the general population? Infertility population?)
You mention converting original scores for the FertiQol into standard scores - what does this
mean? This should be explained in the Methods section.
Table 3:
The Treatment FertiQol section stratified into it’s two components but the Core FertiQual is not
stratified into its four components. Please include the stratification for the Core components, as
this adds more granular information.
Predictors of FertiQol:
The discussion on variables should be in the Methods section not the Results section.
Please identify the specific statistics in the results text. When stating that social concern is the
strongest predictor, include the SB value. You can also comment on marital status having the
most positive impact on QOL scores - include the SB here as well.
Please explain what you mean when you state that these variables combined explain 44.5%
of the QOL scoring and that social concern explains 29.3% of the variance. Where are these
percentages coming from in this table?
Discussion:
You state that patients undergoing frozen embryo transfer may have better quality of life than
those with fresh transfer, but you have not presented data to make this claim. How do these
scores compare to what we know? You cite 3 studies but do not state if these are from fresh
embryo transfer cycles or frozen (you state “mixed population” in the sentence). Additionally,
the scores reported in your study appear similar to the Shenyang study and considering the
standard deviation, likely not different from the Lanzhou study.
If you are going to compare to quality-of-life scores from fresh embryo transfer cycles, you need
to confirm that the patient populations are similar (age, infertility diagnosis and duration, parity,
treatment). Otherwise, you are comparing two different groups and cannot draw a conclusion.
When commenting on the QOL scores from the USA, you again need to confirm if this was for
women undergoing fresh or frozen embryo transfer cycles (or both).
When discussing the Lanzhou City study, you should repeat your results here, so readers do not
need to scroll back up to the table. Additionally, why would recovery from a treatment differ in
a different city? This requires further explanation.
Please state the difference between anxiety state and anxiety trait in the methods section,
especially since you have a paragraph on anxiety in the discussion. This is confusing with those
of us not intimately familiar with these models.
It would be nice to compare anxiety scores to other women with infertility from previous studies,
not just the general Chinese population, if that data is available. Additionally, if there appears
to be a difference between women undergoing fresh and frozen embryo transfer cycles.
You state, “compared with the first marriage, remarried women have better fertility quality of
life”. Please give the data to support this. If this from the literature or did you find this in your
study? Please list the comparative scores.
Conclusion:
You cannot state that women undergoing frozen embryo transfer have higher quality-of-life as
this is a cross-sectional study without a comparator group of those undergoing fresh embryo
transfer.
This is the first time you mention interventions. You should mention this in the Discussion
section and offer some examples.
This is also the first time you mention patient education. This should also be discussed in the
Discussion section and recommendations given there. Perhaps you can also discuss provider
education, as this is crucial if we are to institute any interventions to improve QOL.
The conclusion should not include any new ideas. This should be a summation of the main points
of the study and discussion.
Grammar Edits:
The manuscript needs significant edits with regard to grammar and spelling. Some examples are
listed below, but I recommend having the submission be reviewed by an expert in the English
language.
Scoring systems should be capitalized throughout the text - ie) Fertility Problem Inventory and
Fertility Quality of Life Scale. For the FertiQOL, Core and Treatment should also be capitalized
as they describe the scoring system.
Acronyms should be introduced prior to their use.
Background:
IVF-ET is not a commonly used phrase in the field. Can simply say IVF or IVF cycles.
Frozen-thawed embryo transfer can also be referred to as frozen embryo transfer.
I do not recommend calling the treatment process painful.
Egg collection should be referred to as egg retrieval or oocyte retrieval.
The sentence “in addition, frozen-thawed embryo…” needs to be reworded as it does not make
sense as written. I believe the authors are trying to say that frozen embryo transfer decreases the
risk for OHSS for high responders. Additionally, some data show that frozen embryo transfer
may improve outcomes given improved embryo-endometrial synchronization.
Results:
Treatment data of participants: “mainly from women’s side” should be referred to as “female-
factor infertility”
Discussion:
How does the “condition of one’s uterus” compare to quality-of-life? This sentence is confusing
and should be reworded.