Role of Nurse in Administrating Induction of Ovulation Medications at Assisted Reproduction Center versus at Home

Background: The response of ovaries during controlled ovarian stimulation is the 
most important factor for evaluating the pregnancy outcome in assisted 
reproductive techniques. Aim: The study is to assess the role of a nurse in giving induction of 
ovulation medications at assisted reproduction university center versus home 
medications by private In Vitro Fertilization and infertility center on 
clinical outcomes and patient satisfaction. Subjects and Methods: Case-control research design, conducted 
at two centers (Banon private center for IVF and Assisted Reproductive Unit at 
Women health hospital, Assiut University) during the period from February 2018 to 
November 2018. The sample size included 150 women undergoing IVF for each group. Results: There is no statistically significant difference 
between women given IVF medications by the nurse at the public IVF center and 
women take IVF medication in the home at Banon IVF center as regards the 
outcome of IVF. Majority of infertile patients are satisfied with the care, they 
received and nearly third of them are satisfied with outcome of IVF in both 
groups, and there is statistically significant difference between satisfaction 
in public IVF center and satisfaction in private center in relation to information 
provided about IVF procedure, staff willingness to listen carefully and help 
patients; regular progress update on condition is in place with p value (0.000, 0.005, 0.003) respectively. Conclusion: IVF outcome isn’t significantly 
related to where induction medication was taken either at IVF center or at the 
home because infertile couples are keen to comply with all instructions on how to 
take medications with correct route, correct dose and on time. Recommendations: Empower the role of nurse as a health educator for women undergoing 
IVF about importance of stage of induction and take medications with correct route, correct dose and on time on outcome of IVF; other 
studies should also be conducted in other centers to further investigate the 
issue.


Introduction
After more than 20 years of research, the first IVF child was conceived in England in 1978 and as a result of using IVF technique; more than 250,000 children were conceived from this point forward [1].
The response of ovaries during controlled ovarian stimulation is the most significant factor in evaluating the pregnancy outcome in assisted reproductive technique [2].
The response of ovaries to stimulation with exogenous gonadotropins during IVF is a critical determining factor of live birth rates and adverse outcomes [3].
Poor response to ovarian stimulation, which resulted in cycle cancelation, was defined as a serum E2 level of ≤500 pg/mL and ≤two follicles > 16 mm seen on transvaginal ultrasonography on the day of human chorionic gonadotropin (hCG) administration [4].
Patients' satisfaction with medical care is increasingly acknowledged to be one of the fundamental dimensions of quality of care, and particularly so when it comes to treatment in aid of infertility [5].
Patient satisfaction is an important and commonly used indicator for measuring quality in health care. Patient satisfaction affects clinical outcomes, patient retention, and medical malpractice claims. It affects the timely, efficient, and patient-centered delivery of quality health care. Patient satisfaction is thus a proxy but a very effective indicator to measure the success of doctors and hospitals [6].
Although infertile couples are consulting gynecologists for therapy, a nurse-midwife is the first care provider to contact the couples. Nurse-midwives are responsible to provide holistic care to couples with infertility problems [7].
The IVF nurse performs a significant role in the care received by both recipient and donor, as a coordinator for IVF cycles and provides direct care to both patients. According to one study, the nurse is the professional who spends the most time with donors compared with doctors and mental health professionals.
They also play a major role in matching donors/recipients. In another study, 73% of nurses practicing in infertility settings described their primary role in direct patient care [1].
Morris studied the role of infertility nurses in ovulation induction programs and found that nurses performed intrauterine inseminations in 39% of units and

Significance of the study
Infertility is estimated to be as high as 186 million individuals globally. Recent global demographic surveys reveal that infertility continues to be a reproductive problem, in spite of the massive global increase of ART services over the past decade. It is estimated that infertility affects 8 to 12 percent of reproductive-age couples around the world. However, the infertility rates are much higher in some regions of the world, reaching 30% in some regions [8].
Ovarian stimulation in IVF is considered to be a critical factor for clinical outcomes. Poor ovarian response (POR) to controlled ovarian hyperstimulation is one of the key problems in assisted reproductive technology and has been reported to occur in 9 -24 percent of women with IVF that can result in cycle canceling [7].
Increasing patient satisfaction with IVF services, treatments and facilities has a positive effect on patients' psychological and mental state and, in turn, has an impact on the outcome of treatments and dropout rates of treatment [5]. So, this study will shed more light on whether outcomes of IVF in women taken IVF medications in IVF center better than women took IVF medications at the home and patient satisfaction with IVF services in two centers.

Aim of the Study
The aim of this study was to: 1) Assess role of the nurse in giving induction of ovulation medications at assisted reproduction center versus home medications by private IVF center on outcomes of IVF; 2) Evaluate patient satisfaction in both centers.

Methods of data collection:
A review of national and international related literature of the current study using textbooks, articles and scientific journals was done. Then the tool was prepared based on this literature and it was reviewed for validation by supervisors.
Before conducting the study official permission was obtained from the manager of Banon center and Assisted Reproductive Unit of Women's Health Hospital after explaining the purpose of the study.
The study was carried out during the period from February (2018)  Group one (case group) was given IVF medications by a nurse at the public IVF center.
Group two (control group) was given IVF medication at home at Banon IVF center.  Assessment phase • The researcher interviewed the women face to face; each interview took about 15 -30 minutes with each woman, the researcher interviewed the woman at the stage of induction of ovulation, and at the beginning of each interview, the researcher greeted, introduced herself to the woman after that the researcher explained the nature and aim of study, and then an oral consent to participate in the study was obtained from each woman.
• Then, the researcher assessed the following data 1) Personal data, menstrual history, infertility history & past obstetric history if present.
2) Data related to IVF medications (Name of medication given, person who gave it (doctor-nurse-others), where IVF medications were taken, time of giving medications according to the followed protocol, any problems with medications). 1 represents "Completely dissatisfied"; 2 represents "Mostly dissatisfied"; 3 represents "Somewhat dissatisfied"; 4 represents "neither satisfied nor dissatisfied", 5 represents "Somewhat satisfied"; 6 represents "Mostly satisfied" and 7 represents "Completely satisfied". 2) There was no risk of study subjects during the application of the research.
3) The study was followed by common ethical principles in clinical research. 4) Written consent was obtained from each patient or guidance that was willing to participate in the study. 5) Confidentiality and anonymity were assured. 6) Patients privacy was considered during the collection of data.  Statistical design Data entry and statistical analysis were done using the statistical package for social science program (SPSS. version 22). Qualitative variables were presented as number and percentage. Quantitative variables were presented as mean ± SD. A comparison between qualitative variables was done by using chi-square.
A comparison between quantitative variables was done by using the student t-test.

Results
The socio-demographic (Table 1) characteristics of the study sample, nearly half of the women in both groups were 30 -37 yrs old. As for residence, the vast M. R. Ahmed et al.    (Table 3 and Table 4), more than two-thirds of studied women in both groups (80%, 71.3%) had primary infertility. Regarding to the causes of infertility it was observed that more than third of studied women (35.3%) in assisted reproduction unit in women health hospital and (32%) in Banon center had a male cause of infertility and the vast majority of studied women in both groups (91.3%, 89.3%) hadn't the previous attempt of IVF.
Regarding outcome of IVF in women in both groups (Table 5 and Table 10), there is no Statistical significant difference between women given IVF medications by nurse at public IVF center and women take IVF medication in the home at Banon IVF center in relation to outcome of IVF and the Multinomial logistic regression (Table 7) to identify variables that effect on the outcome of IVF shows that the most variable that effects on pregnancy rate is previous gravidity odds ratio (2.235) followed by occupation and education odds ratio (1.697, Open Journal of Obstetrics and Gynecology   Regarding patient's satisfaction in both centers (Table 8)  Completely satisfied Open Journal of Obstetrics and Gynecology significant difference between satisfaction in public IVF center and satisfaction in private center in relation to information provided about IVF procedure, staff willingness to listen carefully and help patients (Table 9 and Table 10) & Regular progress update on condition is in place with p.v (0.000, 0.005, 0.003) respectively. There was not any significant difference regarding the patient satisfaction with the IVF outcome in both groups (Table 6).

Discussion
IVF cycle success depends on the ability to obtain a sufficient number of mature eggs. The ovarian response during controlled ovarian hyperstimulation (COH) is, therefore, the most important factor in evaluating the outcome of pregnancy in assisted reproductive technique [2].
The response of ovaries to stimulation with exogenous gonadotropins during IVF is a critical factor in determining of live birth rates and adverse outcomes [3].
The satisfaction of patients with medical care is increasingly recognized as one of the fundamental dimensions of quality of care, especially when it comes to infertility treatment [5].
Thus, the present study aimed to assess the role of the nurse in giving induction of ovulation medications at assisted reproduction center versus home medications by private IVF center on outcomes of IVF and to measure patient satisfaction toward the outcomes of IVF in both centers.
Regarding the type of infertility, the present study explored that more than two-thirds of studied women in both groups had primary infertility.
Regarding the causes of infertility, the study revealed that the malefactor of infertility was the common cause of infertility in both centers respectively.
Regarding the female causes of infertility, it was observed that the common female cause of studied women in both groups was blocked fallopian tubes followed by polycystic ovarian syndrome in both groups. This is a first study compare satisfaction in public IVF center & satisfaction in private IVF center.

Study Strengths & Limitations
Merits 1) The prospective way of the study & two centers included.
2) The new idea and it doesn't apply in Egypt before.

Limitations
The difficulty of follow up (it was difficult to call some women for follow up and some of them were missed).

Conclusions
The present findings can be concluded that there was no statistically significant difference between women given IVF medications by nurse at public IVF center and women taking IVF medication at home at Banon IVF center in relation to outcome of IVF as all study sample are keen to comply with all instructions about how to take medications with correct route, correct dose and on time to realize their dream of having a child even those taking IVF medication at home.
The majority of infertile patients were satisfied with the care they received but M. R. Ahmed et al. Open Journal of Obstetrics and Gynecology there was a statistically significant difference between satisfaction in public IVF center and satisfaction in the private center as regards information provided, staff willing to listen carefully and help patients, regular progress update on condition in place.

Recommendations
Based on the results of the present study, the researcher suggested the following recommendations: 1) Empower the role of the nurse as a health educator for women undergoing IVF about the importance of stage of induction and take medications with the correct route, correct dose and on time on the outcome of IVF.
2) More studies should be conducted in other centers to further investigate the issue and re-confirm the reliability and validity of the assessment instrument in evaluating patient's satisfaction, for it to be applied at IVF centers.
3) Medical staff should spend more time on consultation and explanation for women undergoing IVF to raise patient satisfaction.