Reviewer's report
Title:Assisted Reproduction: What factors interfere in the professional's
decisions? Are single women an issue?
Version: 2Date:1 December 2010
Reviewer: Lone Schmidt
Reviewer's report:
Review BMC Women’s Health
Zachia et al. Assisted reproduction: what factors interfere in the professional’s
decisions? Are single women an issue?
This is an interesting study investigating health professionals’ views on decisions
regarding four different special cases of patients asking for fertility treatment. The
question posed is well defined and the methods used are appropriate. The
results are presented clearly and the text is well-written.
I have the following comments:
Major compulsory revisions
1. Background
It is stated that “new IVF-based techniques have detached conception from
sexual intercourse thus enabling the involvement of a third party in the
reproduction process, and has thereby challenged the traditional family identity”.
Insemination with donor semen has been going on for more than 100 years in the
health care sector, so detaching conception from sexual intercourse is not
introduced by the new IVF-based techniques, but is an old story. I will
recommend to re-phrase this sentence.
2. Methods
a) It is not clear from the description of case 1 whether “no intention of having a
partner” covers only a male partner or a female as well. Whether or not case 1 is
a heterosexual case and/or homosexual could have an impact of the participants’
responses. Please, clarify the case text.
b) A more detailed description of the questionnaire data is needed. For example:
How was the participants’ moral values investigated (items and response key),
etc. for moral and technical values/aspects.
c) I do not understand what it means that “the qualitative variables were
described as absolute and relative frequencies”, and further, what are the
“qualitative variables” in this study? Please, clarify the text.
3. Results
The authors’ argue for presenting only results based on case 1 (single women
seeking treatment), as this was the only case with different responses between
countries. However, I find it of importance to present a few data regarding
whether to perform the procedure or not in the 3 other cases investigated.
4. Discussion
a) In the study are included three European countries (Germany, Greece, Italy).
All three countries are oriented towards nuclear families/traditional families and
this could be one of the reasons why a difference to Brazil in case 1 is found. If
instead other European countries as Sweden, Denmark, the Netherlands where
single motherhood is frequent had been included, it is reasonable to believe
there would have been no differences between countries. I recommend the
authors to make this point more clear in the text and not state in general that this
“might be the case in European countries”.
b) It is recommended to include more studies about disclosure/non-disclosure
among single mothers (heterosexual or lesbian) in the discussion. As the authors
are aware the circumstances in relation to disclosure is very different in
single-mother-headed families compared to heterosexual couples where there is
a father.
c) It is recommended to make it clear that disclosure includes several steps. For
example: disclosure of the conception by fertility treatment; by the use of donor
semen; by the use of anonymous/non-anonymous donor semen; by the
possibilities of achieving information about donor identity when grown up.
To my knowledge, previous studies have shown that it can be harmful for the
child if the use of donor insemination is kept as a secret but (very frequently)
known to other people. But the use of anonymous donor semen (vs. identity-
known donor semen) has to my knowledge not been shown to be associated with
negative effects on the family relationship.
d) I miss a discussion of the gender differences reported (more women would
perform the treatment in case 1) – especially in a journal on Women’s Health.
Minor essential revisions
1. I will recommend to use the revised ART-glossary (Zegers-Hochschild et al.,
Hum Reprod 2009;24:2683-87) and use “Medically Assisted Reproduction
(MAR)” instead of ART. MAR includes all kinds of fertility treatment from
ovulation induction, insemination and to ART treatment. The cases in this study
covers both insemination treatments and ART (=in vitro techniques as IVF, ICSI
etc); therefore MAR is the concept including all kinds of treatments described in
the four cases.
2. Abstract
It is mentioned twice in the Method paragraph that socio-demographic variables
have been collected.
3. Discussion
Please, follow reference style and correct references to “(Correa, 2001)” and to
“(3). American Society for Reproductive Medicine, Birmingham, Alabama, 2009.”
4. Table I
Working in a public center and a private center sums up to more than 100%. Is
this because participants are working in both private and public at the same
time?
5. Table II-IV
Please, change in the title and explain in short case 1. As it is now it is not
possible to understand the table without reading the text as well.
Delete the “0” before next digit (not “02” but “2”, etc.)
Is “Especialization” (table IV) “specialization”?
Discretionary revisions
1. The Methods section will benefit from sub-headings, as e.g. Study population;
Data collection; Statistical analyses.
Furthermore, it will be beneficial if a short text about whether it is legal or not in
each of the 4 countries included to perform the treatment in each of the four
specific cases described. This is valuable information for the reader when
studying the results.
2. Also the Discussion section will benefit from sub-headings. As it stands now it
is a little difficult to follow. It would probably also be beneficial to have in one
place only the discussion of the impact of working in the private sector on the
decisions. It is mentioned several places in the text now.
Level of interest: An article of importance in its field
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I declare that I have no competing interests.