Experiences of Transition to Motherhood Among Pregnant Women Following Assisted Reproductive Technology: a Systematic Review Protocol of Qualitative Evidence

SYSTEMATIC REVIEW PROTOCOL

Experiences of transition to motherhood among pregnant women following assisted reproductive technology: a systematic review protocol of qualitative evidence

1,2 1,2 1,2 1,2 1,2 Kunie Maehara Hiroko Iwata Mai Kosaka Kayoko Kimura Emi Mori

1Graduate School of Nursing, Chiba University, Chiba, Japan, 2The Chiba University Centre for Evidence Based Practice: a Joanna Briggs Institute Affiliated Group

ABSTRACT

Objective: This systematic review aims to identify and synthesize available qualitative evidence related to the experiences of transition to motherhood during pregnancy in women who conceived through assisted reproductive technology (ART). Introduction: Women who conceived through ART experience pregnancy-specific anxiety and paradoxical feelings, and face unique challenges in their identity transition to motherhood. It is important for healthcare professionals working with these women to understand the context and complexity of this special path to parenthood, including the emotional adaptation to pregnancy following ART. A qualitative systematic review can provide the best available evidence to inform development of nursing interventions to meet the needs of pregnant women after ART. Inclusion criteria: This review will consider any qualitative research data from empirical studies published from 1992–2019 in English or Japanese that described experiences of transition to motherhood during pregnancy in women who conceived with ART. Methods: This review will follow the JBI approach for qualitative systematic reviews. Databases that will be searched for published and unpublished studies include MEDLINE, CINAHL, PsycINFO, ProQuest Health & Medical Collection, Google Scholar and Open Access Theses and Dissertations (in English), and Ichushi-Web, CiNii and the Institutional Repositories Database (in Japanese). Titles and abstracts will be screened by two independent reviewers in full. The full-text of selected studies will be assessed in detail, and findings and their illustrations will be extracted and aggregated. Any disagreements between the reviewers that arise at each stage will be resolved through discussion, or by a third reviewer. Keywords Assisted reproductive technology; experience; motherhood; pregnant women; qualitative research JBI Evid Synth 2020; 18(1):74–80.

Introduction procedures that include the in vitro handling of ore countries are providing access to assisted human oocytes and sperm or embryos for the M reproductive technology (ART) within their purpose of establishing pregnancy. In IVF, eggs healthcare systems, and an increasing number of are removed from a woman’s ovary and fertilized children are being conceived through ART. These with sperm outside of the body. The fresh or frozen technologies include in vitro fertilization and embryo is transferred to the woman’s uterus. In embryo transfer (IVF-ET), intracytoplasmic sperm ICSI, a single sperm is injected directly into each injection (ICSI) and gamete intrafallopian transfer egg in a laboratory procedure. Finally, GIFT is a (GIFT). These technologies are treatments or process where the eggs and sperm are mixed and then placed in the woman’s fallopian tubes to establish pregnancy. Among 52 countries, Japan Correspondence: Kunie Maehara, [email protected] reported the largest number of ART cycles in 1 The authors declare no conflict of interest. which follicles were punctured and aspirated. DOI: 10.11124/JBISRIR-D-19-00071 The percentage of total live births resulting from

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ART in Japan has increased from 0.5% in 1996 to with women who spontaneously conceived. How- 5.5% in 2016.2 ever, methodological limitations and confounding Various studies have described experiences spe- factors may explain the inconsistencies in previous cific to pregnancy after ART. Women who become findings regarding the impact of ART. In particular, pregnant after infertility were reported to have previous systematic reviews only included quantita- greater specific anxiety, such as fetal survival and tive studies. A narrative review that included both normality3-6 and other complex issues.5,7 In early qualitative and quantitative studies indicated that pregnancy, these women reported experiencing par- women have higher levels of anxiety in pregnancy adoxical feelings such as joy and fear, or hope and after infertility treatment, and may experience some uncertainty,8,9 and had difficulty perceiving them- difficulties in the transition to parenthood, leading to selves as pregnant women.10,11 The transition to perinatal morbidity.20 Other qualitative studies sug- motherhood generally begins when a woman finds gested that the process of assuming a maternal out she is pregnant, and represents a process of active identity during the transition to motherhood may engagement.12 However, following ART, pregnant be qualitatively different for pregnant women who women must go through role acquisition and adjust- conceived through ART.11,13,14,16,21 Women who ment, while potentially experiencing anticipatory conceived via ART may also require more support anxiety about the potential loss of a pregnancy or from nurses/midwives to address anxiety during fetus, and feeling ambivalent over the transition pregnancy and allow them to express any negative from an ‘‘infertile’’ identity to a ‘‘pregnant’’ iden- feelings, review their infertility experiences and help tity.5,11,13,14 Women who have undergone ART may them prepare for parenthood.21-23 Understanding also delay developing an attachment to the fetus and the context and complexity of emotional adaptation preparing for the maternal role.15-17 Bernstein13 to pregnancy following ART is important for health- identified various factors that contribute to mother- care professionals working with these women. In ing disturbances after infertility, including a lack of particular, healthcare professionals need to remain appropriate role models for mothering after infertil- sensitive to the special path to parenthood for ity, delayed attachment to the baby, and the dispar- women after ART16 and their paradoxical care needs ity between the image and actual experience of during pregnancy.24 A qualitative systematic review motherhood. During pregnancy, women who have can provide the best available evidence to inform undergone ART face unique challenges in terms of development of nursing interventions to meet the their transition to motherhood. needs of this population. A quantitative systematic review by Hammarberg A preliminary search of PROSPERO, the JBI et al.18 explored the psychological and social aspects Database of Systematic Reviews and Implementa- of pregnancy after assisted conception. This review tion Reports, the Cochrane Database of Systematic concluded that after ART, women had higher anxi- Reviews, CINAHL and MEDLINE was conducted. ety about the survival of the fetus and more early This search identified two quantitative systematic parenting difficulties compared with women who reviews that addressed psychosocial aspects of preg- spontaneously conceived. However, evidence nancy after ART.18,19 However, no current or under- regarding women’s emotional adjustment to preg- way qualitative systematic reviews on experiences of nancy after ART is inconclusive, with some studies transition to motherhood during pregnancy among suggesting it is problematic and others indicating women who conceived through ART were identi- there are self-protective delays in believing in the fied, other than those focused on prenatal care by pregnancy,11,13,14 forming an emotional attachment midwives.25 In addition, previous systematic reviews to the fetus,11,17 and preparing for life with a baby.11 only covered literature published in the English Another quantitative systematic review by Gour- language,18,19 and although they included East Asian ounti19 revealed that women who conceived after studies, Japanese literature was excluded. In Japan, IVF had greater pregnancy-specific anxiety, lower nursing researchers often publish qualitative quality of life, the same or lower levels of depressive research findings in the Japanese language to dissem- symptomatology, the same level of self-esteem, more inate implications from narratives to clinical prac- positive attitudes toward pregnancy demands, and tice. The increasing practice of ART in Japan over higher levels of maternal-fetal attachment compared the previous two decades has produced a growing

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number of Japanese studies regarding pregnancy becoming a mother26; psychosocial adaptation in after infertility.9,11,14,23 Findings from these studies pregnancy; expressed maternal identity; perceived have not been reflected in previous systematic maternal role and behaviors; and bonding with reviews. We conducted a preliminary search of the fetus during pregnancy. Studies where data were Ichushi-Web, a bibliographic database containing collected outside the pregnancy period, and those biomedical journals and other serial publications based on narratives from other people (e.g., pregnant published in Japan, and no qualitative systematic women’s mothers, partners, friends, siblings) will be reviews addressed this topic. Therefore, this system- excluded. In addition, we will only include studies in atic review will include studies published in English which healthcare professionals (regardless of their or Japanese to provide cumulative insights, create sex) collected empirical data. We intend that the understanding of the transition to motherhood qualitative evidence obtained in our review will among pregnant women following ART and guide help healthcare professionals, such as nurses and future research to develop best practice for these midwives, improve their care for pregnant women women. after ART. Our review will also exclude studies that This systematic review aims to identify and syn- only focused on specific topics, such as disclosure of thesize the available qualitative evidence related to the use of donor gametes, surrogacy, same-sex par- the experiences of transition to motherhood during enting, multiple pregnancy, multi-fetal reduction, pregnancy in women who conceived through ART. sex selection, pre-implantation genetic diagnosis, any fetal abnormality, pregnant women with special Review question needs (e.g., spinal injuries, deafness) and secondary What are the experiences of transition to mother- infertility. hood during pregnancy among women who conceived through ART? Context All primary studies with data collected through Inclusion criteria interviews and observations will be considered, inde- Participants pendent of the location (e.g. healthcare facilities, This review will consider studies that explored the home visits) where these data were collected. experiences of transition to motherhood during pregnancy among women who conceived through Types of studies ART. In this review, ART includes IVF-ET, ICSI This review will consider empirical studies that focus and GIFT. Studies that only focused on intrauterine on qualitative data including, but not limited to, insemination (IUI) or ovulation induction (OI) will designs and methods such as phenomenology, be excluded. These methods are less invasive forms grounded theory, ethnography, qualitative descrip- of fertility treatment. Women undergoing OI take tion, qualitative content analysis and thematic anal- medications to stimulate ovaries to produce more ysis. Qualitative data from mixed methods studies eggs, whereas IUI refers to a procedure of inserting will also be included. Studies that use statistical prepared sperm into the uterus. Studies including reports of results, clinical case reports, historical mixed samples in which some women underwent analysis, review articles, meta-analyses or meta-syn- ART and others were treated with IUI or OI will be theses, editorials, commentaries, letters, conference retained. In addition, this review will only consider abstracts, and studies with no available full text will studies with the collaboration of adult women be excluded. (aged 20 years), regardless of their marital Over the previous 20 years, ART has become status, residential area or whether they used donor common globally, and ART practice has changed gametes. with increasing use of ICSI rather than conventional IVF.1 The first baby in the world resulting from ICSI Phenomena of interest was born in 1992, and the first in Japan was born in This review will consider studies that described 1994. Therefore, studies published from 1992–2019 the experiences of transition to motherhood during in English or Japanese will be considered for this pregnancy in women who conceived through ART, systematic review, as we are currently unable to including perceptions, meanings or experiences of translate studies published in other languages.

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Methods will be reported in full in the final systematic review The proposed systematic review will be conducted in and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) accordance with the JBI methodology for systematic 27 reviews of qualitative evidence. flow diagram. Search strategy Assessment of methodological quality The search strategy will aim to locate published and Eligible studies will be critically appraised by two unpublished studies. The PICo framework (popula- independent reviewers for methodological quality tion, phenomena of interest and context) will be used using the standard JBI Critical Appraisal Checklist 28 to identify the search terms in the review question. An for Qualitative Research. The reviewers deter- initial limited search of MEDLINE (English lan- mined that questions 2, 3, 4, 5, and 10 on the critical guage) and Ichushi-Web (Japanese language) was appraisal checklist are essential for methodological conducted, followed by an analysis of text words quality. Papers will be excluded if they are rated contained in the titles and abstracts, and index terms ‘‘no’’ for any of those questions. Any disagreements used to describe the articles. An example search relating to methodological quality between the strategy for MEDLINE is presented in Appendix I. reviewers will be resolved through discussion, or The reference lists of all studies selected for critical by a third reviewer. Authors of papers will be con- appraisal will be screened for additional studies. tacted to request missing or additional data where clarification is required. The results of the critical Information sources appraisal will be reported in narrative form and in The databases to be searched for published studies a table. will include: MEDLINE, CINAHL, PsycINFO, ProQuest Health & Medical Collection (limited Data extraction to literature written in English) and Ichushi-Web Qualitative data will be extracted from papers (literature written in Japanese). The search for gray included in the review using a standardized data literature will include Google Scholar and Open extraction tool for qualitative evidence (JBI Access Theses and Dissertations (in English), and SUMARI). The extraction will be performed by CiNii and the Institutional Repositories Database, two independent reviewers. To ensure consistency which are Japanese database services that can be during the extraction process, the two reviewers will searched for academic information from articles, meet to compare the extracted data in a Microsoft books, journals and dissertations (in Japanese). Word (Redmond, Washington, USA) document before entry into the JBI SUMARI data extraction Study selection form. The extracted data will include specific details Following the database searches, all identified cita- about the populations, context, culture, geographi- tions will be collated and uploaded into EndNote cal location, study methods and phenomena of inter- basic (Clarivate Analytics, PA, USA), and duplicates est relevant to the review question and specific removed. Titles and abstracts will then be screened objectives. Findings and their illustrations will be by two independent reviewers in full, and citation extracted and assigned a level of credibility. Findings details imported into the JBI System for the Unified will be described as ‘‘unequivocal’’ or ‘‘credible’’, as Management, Assessment and Review of Informa- recommended in the JBI Reviewer’s Manual.28 All tion (JBI SUMARI; Joanna Briggs Institute, Ade- ‘‘unsupported’’ findings will be excluded from the laide, Australia). The full text of selected citations review. Any disagreements relating to credibility that will be assessed in detail by two independent arise between the reviewers will be resolved through reviewers against the inclusion criteria. Reasons discussion, or by a third reviewer. Findings and their for exclusion of full-text studies that do not meet illustrations from literature published in English will the inclusion criteria will be recorded and reported in be translated into Japanese, and those from literature the systematic review. Any disagreements between published in Japanese will be translated into English the reviewers that arise at each stage of the study by two independent translators. Then, reviewers selection process will be resolved through discussion, who are familiar with the issue under study will or by a third reviewer. The results of the screening check the translations for equivalent meaning.

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Data synthesis 3. McMahon CA, Ungerer JA, Beaurepaire J, Tennant C, Saun- Where possible, qualitative research findings will be ders D. Anxiety during pregnancy and fetal attachment pooled using JBI SUMARI with meta-aggregation. after in-vitro fertilization conception. Hum Reprod This will involve the aggregation or synthesis of 1997;12(1):176–82. findings to generate a set of statements that represent 4. Hjelmstedt A, Widstro¨mA,WramsbyHM,CollinsA.Patternsof emotional responses to pregnancy, experience of pregnancy aggregation, through assembling and categorizing and attitudes to parenthood among IVF couples: a longitudinal these findings based on similarity in meaning. These study. J Psychosom Obstet Gynaecol 2003;24(3):153–62. categories will then be subject to synthesis to pro- 5. Lin Yn, Tsai Yc, Lai Ph. The experience of Taiwanese women duce a single comprehensive set of synthesized find- achieving post-infertility pregnancy through assisted repro- ings that can be used as a basis for evidence-based ductive treatment. Fam J 2013;21(2):189–97. practice. The categories and synthesized findings will 6. Netto Dornelles LM, MacCallum F, de Ca´ssia Sobreira Lopes be agreed by discussion among the reviewers to R, Piccinini CA, Pandol Passos E. ‘Living each week as ensure they support the meaning of the translated unique’: maternal fears in assisted reproductive technology data. Where textual pooling is not possible, the pregnancies. Midwifery 2014;30(3):e115–120. findings will be presented in narrative form. 7. Crespo E, Bestard J. Psychosocial needs of women and their partners after successful assisted reproduction treatment in Assessing confidence in the findings Barcelona. Reprod Biomed Soc Online 2017;3:90–9. 8. Ranjbar F, Akhondi M-M, Borimnejad L, Ghaffari S-R, Beh- The final synthesized findings will be graded accord- 29 boodi-Moghadam Z. Paradox of modern pregnancy: a ing to the ConQual approach for establishing phenomenological study of women’s lived experiences confidence in the output of qualitative research from assisted pregnancy. J Pregnancy 2015;2015:543210. synthesis and presented in a Summary of Findings. 9. Maehara K, Sakajo A, Iwata H, Mikuni K, Aoki K, Mori E. This table will include the major elements of the [Perceptions of pregnancy among pregnant women after review and detail how the ConQual score was devel- assisted reproductive technology: a longitudinal study oped. The table will include the title, population, using sentence completion test.] Journal of Japanese Soci- phenomena of interest and context for the studies ety of Fertility Nursing 2018;15(1):5–14. Japanese. included in the review. Each synthesized finding 10. Olshansky E. A theoretical explanation for previously infer- from the review will be presented along with the tile mothers’ vulnerability to depression. J Nurs Scholarsh 2003;35(3):263–8. type of research informing it and a score for depend- 11. Mori E, Ishii K, Hayashi H. [Prenatal maternal role attainment ability, credibility and the overall ConQual score. after infertility treatment.] Journal of Japanese Society of Fertility Nursing 2007;4(1):26–33. Japanese. Funding 12. Nelson AM. Transition to motherhood. J Obstet Gynecol This study was supported by a Grant for Social Neonatal Nurs 2003;32(4):465–77. 13. Bernstein J. Parenting after infertility. J Perinat Neonatal Welfare Activities from The Mitsubishi Foundation. Nurs 1990;4(2):11–23. 14. Sakiyama T, Muramoto J. [Research on the process of Acknowledgments recognizing ‘‘The self as a mother’’ by women pregnant We thank Dr. Patraporn Tungpunkom, Faculty of via infertility treatment.] Journal of Japanese Society of Nursing, Chiang Mai University, The Thailand Cen- Fertility Nursing 2006;3(1):11–9. Japanese. 15. McMahon CA, Tennant C, Ungerer J, Saunders D. ‘Don’t tre for Evidence Based Health Care: a Joanna Briggs count your chickens’: a comparative study of the experience Institute Affiliated Group, for feedback on the draft. of pregnancy after IVF conception. J Reprod Infant Psychol 1999;17(4):345–56. References 16. McMahon CA. Does assisted reproduction make an impact 1. Sullivan EA, Zegers-Hochschild F, Mansour R, Ishihara O, de on the identity and self-esteem of infertile women during Mouzon J, Nygren KG, Adamson GD. International Commit- the transition to parenthood? J Assist Reprod Genet tee for Monitoring Assisted Reproductive Technologies 1999;16(2):59–62. (ICMART) world report: assisted reproductive technology 17. Maehara K, Mori E, Ozawa H, Maekawa T, Morita A, Iwata H, 2004. Hum Reprod 2013;28(5):1375–90. et al. [Relation of maternal anxiety to feelings toward the 2. Hidekazu S. Report on registration and survey subcommit- infant and maternal role attainment in pregnant women after tee of ethics committee in 2016. Acta Obstet Gynaecol Jpn assisted reproductive technology.] Journal of Graduate 2018;70(9):1817–76. School of Nursing Chiba University 2012;34:1–8. Japanese.

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18. Hammarberg K, Fisher JRW, Wynter KH. Psychological and 24. Warmelink JC, Adema W, Pranger A, de Cock TP. Client social aspects of pregnancy, childbirth and early parenting perspectives of midwifery care in the transition from sub- after assisted conception: a systematic review. Hum Reprod fertility to parenthood: a qualitative study in the Update 2008;14(5):395–414. Netherlands. J Psychosom Obstet Gynaecol 2016;37(1): 19. Gourounti K. Psychological stress and adjustment in preg- 12–20. nancy following assisted reproductive technology and 25. Younger M, Hollins-Martin C, Choucri L. Individualised care spontaneous conception: a systematic review. Women for women with assisted conception pregnancies and mid- Health 2016;56(1):98–118. wifery practice implications: an analysis of the existing research 20. Ranjbar F, Behboodi Moghadam Z, Gharacheh M. Prenatal and current practice. Midwifery 2015;31(2):265–70. care in pregnancies through assisted reproductive technol- 26. Mercer RT. Becoming a mother versus maternal role attain- ogies (ARTs): a narrative review article. J Client-Centered ment. J Nurs Scholarsh 2004;36(3):226–32. Nurs Care 2017;3(4):241–50. 27. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA 21. Sakiyama T. Development and evaluation of the Adaptation Group. Preferred Reporting Items for Systematic Reviews Support Program in Early Pregnancy after the use of and Meta-Analyses: the PRISMA statement. PLoS Med assisted reproductive technology. Jpn J Nurs Sci 2019;16(3): 2009;6(7):e1000097. 286–99. 28. Lockwood C, Porrit K, Munn Z, Rittenmeyer L, Salmond S, 22. French LR, Sharp DJ, Turner KM. Antenatal needs of couples Bjerrum M, et al. Chapter 2: Systematic reviews of qualitative following fertility treatment: a qualitative study in primary evidence. In: Aromataris E, Munn Z (Editors). Joanna Briggs care. Br J Gen Pract 2015;65(638):e570–7. Institute Reviewer’s Manual [Internet]. Adelaide: Joanna 23. Mori E, Sakajo A, Maehara K, Ozawa H, Morita A, Briggs Institute; 2017 [cited 2019 Mar 3]. Available from: Maekawa T. [Developing the nursing intervention pro- https://reviewersmanual.joannabriggs.org/. gram for pregnant women after the artifical reproduc- 29. Munn Z, Porritt K, Lockwood C, Aromataris E, Pearson A. tive treatment to promote maternal role attainment.] Establishing confidence in the output of qualitative Journal of Japan Maternity Nursing 2011;11(1):19–26. research synthesis: the ConQual approach. BMC Med Res Japanese. Methodol 2014;14(1):108.

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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 ¼ ‘‘1992–Current’’)

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