9J Contemp Med Sci | Vol. 2, No. 5, Winter 2016: 9–14 Research Background Infertility is the inability of a person to reproduce by natural means. Infertility may describe a woman who is unable to get conceived as well as being unable to carry a pregnancy to full term. There are many biological and other causes of infertility, including some of the medical interventions can treat. Infertility rates have increased by 4% since the 1980s, mostly from problems with fecundity due to an increase in age. About 40% of the issues involved with infertility are due to the man, another 40% due to the woman, and 20% results from complications with both the partners. In vitro fertilisation and embryo transfer (IVF–ET) was first successfully used in humans over 25 years ago; since then, more than one million children have been conceived using this technology. IVF is a procedure designed to enhance the likelihood of conception in couples for whom other fertility therapies have been unsuccessful or are not possible. It is a complex process and involves multiple steps resulting in the insemination and fertilisation of oocytes (eggs) in a laboratory. The embryos created in this process are then placed into the uterus for potential implantation. Each stage of the procedure is associated with specific risks; IVF may provide a couple who has been otherwise unable to conceive with a chance to establish a pregnancy2. Objective 1. To assess women’s commitment to implementation of IVF 2. To identify short protocol implementation 3. To identify long protocol implementation Methodology Non-probability (purposive sample), the study sample consists of (60) infertile women who were selected from Kamal Al-Samaraee Hospital. The study group consist of (30) infertile women was exposed to follow-up and (30) women is control group the criteria of this sample was infertile women in reproductive age, with different educational levels in the public department were involved in IVF program. Results In the study group, 20 women were using short protocol and 10 were using long protocol. The total number of study group was 30, 9 of them become pregnant, 5 of them were using short protocol and 4 of them were using long protocol. In the control group, there were 20 women using short protocol and 10 using long protocol. The total number of study group was 30; 2 of them become pregnant and were using short protocol. Conclusions Results shows that with respect to study sample, observed significant relationships should be informative and significant level was not achieved. Long protocol are much better than short protocol. In addition to that, results shows that with respect to control sample, no significant relationships are accounted, as well as two types of protocol either long or short gives the same responding. Results shows that significant relationships are accounted and that the study sample recorded six times better than control. Recommendations The study recommended that all the infertile women should be exposed to the implementation of the follow-up and call the patients by phone and through the interview with patients and instruct them about their protocols. Keywords infertility, infertile women, IVF, short protocol, long protocol Effectiveness of infertile women’s commitment to implement in vitro fertilization (long/short) protocols Hawraa Hussein Ghafela, Rabe’a Mohsen Alia, Alaa Hazeem AL-Rahawib ISSN 2413-0516 aDepartment of Maternal and Neonatal Nursing, College of Nursing, University of Baghdad, Baghdad, Iraq. bDepartment of Obstetrics and Gynecology, Kamal Al-Samaraee Hospital, Ministry of Health, Baghdad, Iraq. Correspondence to Hawraa Hussein (email: Hawraa_2004@yahoo.com). (Submitted: 16 November 2015 – Revised version received: 27 December 2015 – Accepted: 23 January 2016 – Published online: 26 March 2016) Introduction Infertility, defined as the inability to become pregnant after 1 year of unprotected sex, is a problem faced by nearly 6.1 mil- lion Americans that is nearly 10% of men and women of reproductive age. Because, this problem is so prevalent, fer- tility treatments abound. Assisted reproductive technology (ART) is a group of fertility treatments that involve both the sperm and the egg. In vitro fertilisation (IVF) is the most common type of ART. In IVF, the sperm fertilises the egg out- side the body, and doctors implant it into the woman’s uterus with hopes of a successful pregnancy. Other forms of ART include intracytoplasmic sperm injection (ICSI), gamete intr- afallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT). The history of IVF is relatively short. Louise Brown of England was the first baby born via IVF, in 1978. The next IVF baby was born later that same year in India. Soon, people started calling these infants as ‘test-tube babies’ which means fertilisation outside of the body. In 1981, the first American test-tube baby was born, and the number has continued to increase each year3. IVF is the most effective ART. It is often used when a woman’s fallopian tubes are blocked or when a man produces very few sperm. Doctors treat the woman with a drug that causes the ovaries to produce multiple eggs. Once matured, the eggs are removed from the woman. They are put in a dish in the lab along with the man’s sperm for fertilisation. After 3–5 days, healthy embryos are implanted into the wom- an’s uterus (American College of Obstetricians and Gynecolo- gists4. The best known of these methods is IVF, which was responsible for the birth of many ‘test-tube babies’. The eggs obtained through the vaginal canal using ultrasound guidance are fertilised with the partner’s sperm outside the woman’s body, not in a test tube, but in a culture dish. A few days later, the eggs, now called zygotes, are placed in the woman’s uterus. mailto:Hawraa_2004@yahoo.com 10 J Contemp Med Sci | Vol. 2, No. 5, Winter 2016: 9–14 Effectiveness of infertile women’s commitment to implement IVF protocols Research Hawraa Hussein Ghafel et al. If one or more of the zygotes implants successfully, pregnancy results. One study reported that 17% of women who under- gone this procedure once, go on to deliver a baby5, in order to maximise success rates with IVF. There are several ovarian stimulation medication protocols that are used to stimulate the ovaries to make enough follicles and eggs. Without stimu- lating medications, the ovaries make and release only one matured egg per menstrual cycle in a month6. IVF is a complex series of procedures used to treat fertility7. IVF is a procedure, used to overcome a range of fertility issues, by which an egg and sperm are joined together outside the body8. In a natural menstrual cycle, the pituitary gland’s luteinising hormone (LH) and follicle-stimulating hormone (FSH) causes the growth of an egg in a fluid-filled follicle within the ovary9. The drugs used for ovarian stimulation have mild side effects in some women, including mild bruising and soreness at the injection site, headaches, an upset stomach and mood swings10. IVF increases the risk of multiple births if more than one embryo is implanted in the uterus11. A pap smear for every 2 years, as well as regular gynaecological and breast examina- tions are currently the best methods to prevent or detect wom- en’s cancers. Use of injectable fertility drugs, such as human chorionic gonadotropin (HCG), to induce ovulation can cause ovarian hyperstimulation syndrome12. The age of the woman has a significant effect on her fertility and the live birth rate decreases significantly from the age 35 years when the woman is using her own eggs13. Female body mass index should ideally be in the range of 19–30 before commencing IVF treatment. Female body mass index outside this range is likely to reduce the success of assisted reproduction procedures14. Approximately 15 years ago, a different type of GnRH analog was developed, called GnRH ‘antagonists’, these medications work differently than the GnRH ‘agonists’ like Lupron15. Methodology The follow-up is made through the phone and interview with patients when they come to hospital. The instructions given to the women during the follow-up includes: information about IVF procedure, teaching the women about the importance of the commitment in the time of taking their medications such as injections, some of the injection are taken in the morning and the other in the evening, in certain time according to the doctor’s instruction, teaching the women about the side effects of medications, teaching the women about the correct site of injection, because some of the injection should be injected in intramuscular and other is injected subcutaneously. The best way to save the drugs without causing damage during trans- port from the hospital, because these medications consist of hormone that gets damaged in the hot and in the cold. The woman should keep it in the door of a refrigerator (informa- tion about the importance of commitment in a time of injection). Information about the complications of IVF may occur. Rather than slowly suppress the pituitary over 4–5 days like Lupron does, these newer medications, Cetrotide and Ganirelix Acetate—rapidly suppress the pituitary in a matter of hours. GnRH antagonist protocols have several advantages over GnRH agonists protocols. The number of daily injections is fewer (4–5 days) of antagonists versus (3–4 weeks) of agonists and the length of time to stimulate the follicles to maturity is 1 or 2 days shorter, so you may need less total gonadotropins. In addition, your chance of developing ovarian hyperstimulation syndrome is less with GnRH antagonist protocols. Multiple research studies have compared IVF agonist and antagonist protocols which mostly showing similar pregnancy rates. Results and Findings Part 1: Distribution of Socio-Demographical Characteristics Variables Table 1 shows distribution of studied groups (with and without) follow-up of IVF (long/short) protocol, in light of ‘socio-demographical characteristics’ variables (SDCv.), as well as comparisons significant are obtained to be sure that two independent groups are thrown from the same population concerning of that variables. Results shows that no significant differences at P > 0.05 are accounted between studied groups, which indicating that two independent groups are thrown from the same popula- tion in light of SDCv. and that are more reliable for this study, since any meaningful differences may be registered among the studied outcomes, should be interpreted by effectiveness of applying (long/short) IVF protocols in light of follow-up or not. Part 2: Distributions of Reproductive Status Table 2 shows distribution of observed frequencies and per- centages of reproductive status, as well as relationships among studied groups with comparisons significant, which shows that two independent groups are thrown from the same popu- lation in light of (reproductive status), and that are more reli- able for this study, since any meaningful differences may be registered among final outcomes, should be interpreted by effectiveness of applying (long/short) IVF protocols in light of follow-up or not. Part 3: Distributions of Effectiveness (Long/Short) IVF Protocols in Light of Follow-up or Not: Relationship among studied groups (with and without follow-up) protocol and final results of program either success or failure program and contingency coefficients are constructed in Table 3 within comparisons significant, as well as an odds ratio and cohort of failure results among (long /short) protocol. Results shows that concerning with follow-up group, observed significant relationships should be informative rather than simply stating that statistical significant level was not achieved. In addition to that, long protocol with fol- low-up stating had four times of success outcomes better than short protocol, as well as cohort to failure outcomes are accounted half effectiveness concerning with follow-up pro- tocol, compared without follow-up group. In addition to that, results shows that concerning without follow-up group, no significant relationships are accounted at P > 0.05, as well as two types of protocol either long or short gives the same responding statistically. Figure 1 represents graphically the distribution of studied groups (with and without) IVF protocol. Discussion of the Results Table 1 shows observed frequencies and percentages of the studied SDCv. which are distributed according to studied 11J Contemp Med Sci | Vol. 2, No. 5, Winter 2016: 9–14 Research Effectiveness of infertile women’s commitment to implement IVF protocolsHawraa Hussein Ghafel et al. Table 1. Distribution studied groups according to socio-demographical characteristics variables (SDCv.) SDCv. Classes (With follow-up) (Without follow-up) C.S. (*) [P-value]No. % No. % Age of wife (years) <20 1 3.3 0 0 C.C. = 0.294 P = 0.339 (NS) 20− 5 16.7 7 23.3 25− 7 23.3 9 30.0 30− 8 26.7 8 26.7 35− 5 16.7 6 20.0 40–50 4 13.3 0 0.0 Mean ± SD 30.5 ± 6.61 28.83 ± 5.82 Age of husband (years) 20− 0 0 2 6.7 C.C. = 0.261 P = 0.497 (NS) 25− 5 16.7 5 16.7 30− 6 20 8 26.7 35− 6 20 8 26.7 40− 11 36.7 6 20 45–50 2 6.7 1 3.3 Mean ± SD 36.33 ± 6.37 34.2 ± 6.35 Rh : wife Pos. 28 93.3 29 96.7 C.C. = 0.076 P = 0.554 (NS)Neg. 2 6.7 1 3.3 Rh : husband Pos. 30 100 29 96.7 C.C. = 0.129 P = 0.313 (NS)Pos. 0 0 1 3.3 Consanguinity Relative 16 53.3 19 63.3 C.C. = 0.101 P = 0.432 (NS)Not relative 14 46.7 11 36.7 Education: wife Illiterate 1 3.3 3 10.0 C.C. = 0.179 P = 0.575 (NS) Graduate of primary 11 36.7 11 36.7 Graduate of secondary 12 40.0 9 30.0 Higher education 6 20.0 7 23.3 Education: husband Illiterate 1 3.3 1 3.3 C.C. = 0.156 P = 0.681 (NS) Graduate of primary 8 26.7 11 36.7 Graduate of secondary 9 30 11 36.7 Higher education 12 40 7 23.3 Occup. wife Employer 24 80 26 87.7 C.C. = 0.089 P = 0.488 (NS)House wife 6 20 4 12.3 Occup. husband Employer 15 50 18 60 C.C. = 0.100 P = 0.436 (NS)Free job 15 50 12 40 Marriage-wife Married before 2 6.7 1 3.3 C.C. = 0.201 P = 0.284 (NS)First wife 26 86.7 23 76.7 Second wife 2 6.7 6 20.0 Marriage- husband Married before 2 6.7 3 10 C.C. = 0.193 P = 0.313 (NS)Not married before 27 90 23 76.7 Polygamous 1 3.3 4 13.3 (*)NS: non sig. at P ≥ 0.05; C.C.: contingency coefficient. samples (with and without follow-up), as well as comparisons significant for relationships. Results shows that no significant differences at P > 0.05 are accounted between the two samples, and that are more reliable for this study, since any meaningful deviation may registered between the studied samples should be interpreted for effectiveness of applying studied follow-up relative to subject’s ‘age groups’; majority of the studied samples are reported at the age ranged (25–29) years for wife, and (40–44) years for husband, then followed with subject’s ‘Rh’, results indicated that most of the studied individuals had a positive results, and they are accounted in light of with and without follow-up 18 (93.3%) and 29 (96.7%) for wife, as well as 30 (100%) and 29 (96.7%) for husband, then followed with subjects of ‘consanguinity status’, results indicated that sample 12 J Contemp Med Sci | Vol. 2, No. 5, Winter 2016: 9–14 Effectiveness of infertile women’s commitment to implement IVF protocols Research Hawraa Hussein Ghafel et al. Table 2. Distributions of reproductive status at the studied samples with comparisons significant Reproductive status Resp. (With follow-up) (Without follow-up) C.S. (*) [P-value]No. % No. % Previous pregnancy Yes 12 40 8 26.7 C.C. = 0.140 P = 0.273 (NS)No 18 60 22 73.3 Previous ectopic pregnancy Yes 2 6.7 2 6.7 C.C. = 0.000 P = 1.000 (NS)No 28 93.3 28 93.3 Previous abortion Yes 5 16.7 6 20 C.C. = 0.043 P = 0.739 (NS)No 25 83.3 24 80 Previous birth of deformed baby Yes 0 0 0 0 C.C. = 0.000 P = 1.000 (NS)No 30 100 30 100 Previous delivery Yes 8 26.7 4 13.3 C.C. = 0.164 P = 0.197 (NS)No 22 73.3 26 86.7 Puerperal fever ( in a secondary infertility) Yes 0 0 0 0 C.C. = 0.000 P = 1.000 (NS)No 30 100 30 100 Fallopian tube obstruction One tub 2 6.7 2 6.7 C.C. = 0.133 P = 0.584 (NS)Both of them 1 3.3 3 10 Opened tubes 27 90 25 83.3 Pituitary gland disorders Yes 5 16.7 3 10 C.C. = 0.098 P = 0.448 (NS)No 25 83.3 27 90 Elevated of prolactine hormone Yes 11 36.7 13 43.3 C.C. = 0.068 P = 0.598 (NS)No 10 63.3 17 56.7 Duration of infertility (years) <5 years 5 16.7 5 16.7 C.C. = 0.181 P = 0.566 (NS) 5–9 15 50 13 43.3 10–14 7 23.3 11 36.7 15–19 3 10 1 3.3 Type of infertility Primary 23 76.7 27 90 C.C. = 0.176 P = 0.166 (NS)Secondary 7 23.3 3 10 The causes of infertility related to your husband Yes 21 70 23 76.7 C.C. = 0.075 P = 0.559 (NS)No 9 30 7 23.3 (*)NS: non sig. at P > 0.05; C.C.: contingency coefficient. of with follow-up are accounted 16 (53.3%), while without fol- low-up sample are accounted 19 (63.3%), then followed with subject’s ‘level of education’, results shows that more of 50% of studied sample of ‘wife’ had graduated secondary school and higher educated and they are accounted for 18 (60.0%) and 17 (53.3%), as well as sample of ‘husband’ are accounted 21 (70.0%) and 18 (60.0%), then followed with subject’s ‘occupa- tion’, results shows that most of the studied samples in light of ‘wife’ had recorded employed, and they are accounted 24 (80%) and 26 (87.7%), as well as sample of ‘husband’ had recorded employed, and accounted in light of with and without follow-up 15 (50.0%) and 18 (60.0%) respectively, and the left- over had free job. Marriage status for wife had recorded mostly first wife, and accounted in light of with and without follow-up 26 (86.7%) and 23 (76.7%) respectively, then finally followed with subject’s ‘marriage status’ for husband had recorded mostly not married before, and accounted in light of with and without follow-up 27 (90%) and 23 (76.7%) respectively. Table 2 shows distribution of the observed frequencies and percentages of reproductive status as well as relationships among studied samples with comparisons significant, and as follows: a. Regarding to subjects ‘previous pregnancy’, results indicated that there has been no significant different at P > 0.05 between studied samples, with 8 (26.7%) at the control sample, while 12 (40%) individuals are accounted at the study sample. b. Regarding to subjects ‘previous ectopic pregnancy’, results indicated that there has been no significant dif- ferent at P > 0.05 accounted between studied samples, with 2 (6.7%) individuals are accounted at the control and study samples. c. Regarding to subjects ‘previous abortion’, results indi- cated that there has been no significant different at P > 0.05 accounted between studied samples, with 6 (20%) at the control sample, while 5 (16.7%) individuals are accounted at the study sample. d. Regarding to subjects ‘previous birth of deformed baby’, results indicated that there has been no individ- uals are accounted at the study and control samples. D id y ou h av e or s uff er in g fro m : 13J Contemp Med Sci | Vol. 2, No. 5, Winter 2016: 9–14 Research Effectiveness of infertile women’s commitment to implement IVF protocolsHawraa Hussein Ghafel et al. Table 3. Distribution of final outcomes results of program and protocol types among (with and without follow-up) of IVF protocol groups with comparisons significant Groups Protocol types No. and percent The final results of program Total C.S. (*) [P-value]Success Failure (w ith fo llo w -u p) Long protocol No. 6 5 11 C.C. = 0.295 P = 0.091 (NS) Odds ratio (1 : 4.0) cohort: (failure) (1 : 0.54) % Type of protocol 54.5% 45.5% 100% % Type of result 66.7% 23.8% 36.7% Short protocol No. 3 16 19 % Type of protocol 15.8% 84.2% 100% % Type of result 33.3% 76.2% 63.3% Total No. 9 21 30 % Type of protocol 30.0% 70.0% 100% % Type of result 100% 100% 100% (w ith ou t f ol lo w -u p) Long protocol No. 0 10 10 C.C. = 0.186 P = 0.301 (NS) cohort: (failure) (1 : 1.11) % Type of protocol 0.0% 100% 100% % Type of result 0.0% 35.7% 33.3% Short protocol No. 2 18 20 % Type of protocol 10% 90% 100% % Type of result 100% 64.3% 66.7% Total No. 2 28 30 % Type of protocol 6.7% 93.3% 100% % Type of result 100% 100% 100% (*)NS: non sig. at P > 0.05; C.C.: contingency coefficient. Fig. 1 Cluster bar charts of final results of program and protocol types at each sample (with and without follow-up) of IVF protocol groups e. Regarding to subjects ‘previous delivery’, results indi- cated that there has been no significant different at P > 0.05 accounted between studied samples, with 4 (13.3%) at the control sample, while 8 (26.7%) individuals are accounted at the study sample. Relationship among studied samples (with and without follow-up) and final results of program either success of program (preg- nancy occur) or failure, contingency coefficients are constructed in Table 3 within comparisons significant, as well as an odds ratio. Results shows that concerning with study sample observed, significant relationships should be informative rather than simply significant level, was not achieved as well as long protocol four times concerning study sample are better than short protocol. In addition to that, results shows that con- cerning with control sample, no significant relation- ships are accounted at P > 0.05, as well as two types of protocol either long or short gives the same responding. How P-value to be reported: ‘If P-value is found as 0.07, it is more informative for that result to be reported, rather than simply stating that statistical significant was not achieved’. 14 J Contemp Med Sci | Vol. 2, No. 5, Winter 2016: 9–14 Effectiveness of infertile women’s commitment to implement IVF protocols Research Hawraa Hussein Ghafel et al. Recommendations 1. The follow-up is very important to implement the commit- ment of IVF protocols through phone and interview with the patient when they come to hospital. 2. The follow-up is to be very effective and guide some of wrong practices of the patients to save the medications by References 1. Wikipedia: In vitro fertilization, 2015. Available at https://en.wikipedia.org/ wiki/In_vitro_fertilisation 2. Georgia reproductive specialists: Overview for IVF patients. Atlanta; 2007. Available at http://www.ivf.com/overview.html 3. Jeffries M. In vitro fertilization overview. HowStuffWorks, 1998–2015. 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