STUDY QUESTION:How were the logbook and curriculum for the Nurses and Midwives Certification Programme of ESHRE developed? SUMMARY ANSWER:The logbook and corresponding curriculum for the ESHRE Nurses and Midwives Certification Programme were based on an extensive literature review, an international expert panel, and a survey of Belgian and Dutch nurses and midwives (N&M) working in reproductive medicine (RM). WHAT IS KNOWN ALREADY:ESHRE has been running a certification programme for N&M working in RM since 2015. To the best of our knowledge, clinical practice guidelines for nursing/midwifery care within RM are lacking as is consensus on role descriptors of N&M working in RM. STUDY DESIGN, SIZE, DURATION:The Nurses and Midwives Certification Committee (NMCC), established by the ESHRE Executive Committee in 2012, decided to gather background information by: (i) systematically reviewing the literature on the tasks of N&M working in RM, (ii) consulting and surveying an expert panel of international senior N&M, and (iii) surveying Belgian and Dutch N&M working in RM across different clinics. Finally, the NMCC developed a logbook and curriculum fostering a more expanded theoretic background. PARTICIPANTS/MATERIALS, SETTING, METHODS:The NMCC comprised four N&M, one clinical embryologist, and one gynaecologist (both in an advisory capacity). The Medline database was searched for papers relating to the tasks of N&M working in RM, by entering a search string in PubMed. In an attempt to capture insight into the tasks and roles of N&M working in RM, the NMCC subsequently surveyed N&M experts across nine countries (Denmark, Finland, France, Norway, Slovenia, Sweden, Turkey, Ukraine, and the UK), and 48 Belgian and Dutch N&M working in RM. MAIN RESULTS AND THE ROLE OF CHANCE:There were 36 papers on the tasks of N&M working in RM originating from 13 countries (in Asia, Oceania, Europe, and North America), identified. Initially, 43 tasks in which N&M working in RM participated, were identified by literature only (n = 5), the international expert panel only (n = 4), Belgian and Dutch N&M working in RM only (n = 5), or a combination of two (n = 13) or three (n = 16) of these sources. The number and composition of tasks included in the logbook were adapted yearly based on novel insights by the NMCC. In response to the annual review, the extended role of N&M working in RM is now reflected in the 2024 version by 73 tasks. Seven specialist tasks (i.e. embryo transfer) were performed independently by N&M working in RM in some countries, while in other countries N&M merely had an 'assisting' role. Candidates are also expected to submit a mature ethical reflection on one clinical case. To support applicants throughout the certification process, the NMCC developed a curriculum in line with all tasks of N&M working in RM. LIMITATIONS, REASONS FOR CAUTION:The literature review was not completed prior to consulting the international expert panel or surveying the Belgian and Dutch N&M working in RM. WIDER IMPLICATIONS OF THE FINDINGS:The differences in tasks and roles of N&M working in RM across and within countries, clinics and individuals illustrated by the literature review, the international expert panel, and the surveyed Belgian and Dutch N&M working in RM suggest an opportunity for structured professional development. Further research is required to elicit the post-certification experience of N&M working in RM and its impact on their professional development. STUDY FUNDING/COMPETING INTEREST(S):The expert panel meeting was funded by ESHRE and the literature review and surveys were supported by Leuven University (Belgium) and the postdoctoral fellowship of the Research Foundation Flanders of E.A.F.D. H.K. received consulting fees and honoraria from Gedeon Richter, Finox and MEDEA, and travel support from Gedeon Richter and Finox. The other authors declare no conflict of interest. TRIAL REGISTRATION NUMBER:N/A.

Abstract Study question What are the current attitudes in Flemish adolescents aged 15-19 towards having children? Summary answer While the majority of adolescents want to have children, 25% have ambiguous feelings about having children and 10% indicate a wish to remain childless. What is known already In the past decades, a very positive attitude towards having children has been reported in young people. In the adult population, most people desire to have children or are already parents, but the group of people who choose to remain childfree is increasingly visible and vocal. The current generation of adolescents is more concerned about environmental impacts than previous generations. Study design, size, duration An anonymous online survey of multiple choice and open-ended questions was offered to adolescents in Flanders (Belgium). Forty – four schools in Flanders participated and 1700 adolescents completed the questionnaire from February 2022 to June 2022. We performed a qualitative analysis of answers in open ended questions. Participants/materials, setting, methods Adolescents aged 15 – 19 years old, attending the last two years of secondary school in Flanders (Belgium). Most pupils had the opportunity to complete the questionnaire during class, others chose to complete the questionnaire in their own free time. Main results and the role of chance The majority of pupils would like to have children (60.2%), a considerable proportion is still undecided (24.7%) and 10.8% report they do not want children. Significantly more boys than girls would like to have children (67% versus 61.7%, p < 0.01). Having a positive representation of children and the desire to build a family in the future are the most important reasons for wanting children. Adolescents who have ambiguous feelings or who do not want children are rather pragmatic in their decision-making. They may consider factors such as financial stability, career goals and personal development before deciding to have children. Other reasons for having an ambiguous or negative attitude towards parenthood reflect the sense of uncertainty in association with the current global situation and socio-political situation. Our data do not allow us to conclude whether the observed decline in the desire for parenthood is a temporary phenomenon closely linked to current events, or a more permanent one. Limitations, reasons for caution Participants were predominantly girls and attended general secondary education. The questionnaire has only been distributed in schools in Flanders and not in the entire country of Belgium due to administrative constraints. Pupils with a positive attitude towards having children may have been more likely to participate in the study. Wider implications of the findings Although reproductive intentions can change over the course of a lifetime, our results suggest that the future fertility rate may decline due to an increasing segment of voluntarily childfree people. A balance may be necessary between removing practical barriers toward parenthood, while acknowledging the legitimacy of other life plans. Trial registration number not applicable

STUDY QUESTION What is the recommended management for couples presenting with unexplained infertility (UI), based on the best available evidence in the literature? SUMMARY ANSWER The evidence-based guideline on UI makes 52 recommendations on the definition, diagnosis, and treatment of UI. WHAT IS KNOWN ALREADY UI is diagnosed in the absence of any abnormalities of the female and male reproductive systems after ‘standard’ investigations. However, a consensual standardization of the diagnostic work-up is still lacking. The management of UI is traditionally empirical. The efficacy, safety, costs, and risks of treatment options have not been subjected to robust evaluation. STUDY DESIGN, SIZE, DURATION The guideline was developed according to the structured methodology for ESHRE guidelines. Following formulation of key questions by a group of experts, literature searches, and assessments were undertaken. Papers written in English and published up to 24 October 2022 were evaluated. PARTICIPANTS/MATERIALS, SETTING, METHODS Based on the available evidence, recommendations were formulated and discussed until consensus was reached within the guideline development group (GDG). Following stakeholder review of an initial draft, the final version was approved by the GDG and the ESHRE Executive Committee. MAIN RESULTS AND THE ROLE OF CHANCE This guideline aims to help clinicians provide the best care for couples with UI. As UI is a diagnosis of exclusion, the guideline outlined the basic diagnostic procedures that couples should/could undergo during an infertility work-up, and explored the need for additional tests. The first-line treatment for couples with UI was deemed to be IUI in combination with ovarian stimulation. The place of additional and alternative options for treatment of UI was also evaluated. The GDG made 52 recommendations on diagnosis and treatment for couples with UI. The GDG formulated 40 evidence-based recommendations—of which 29 were formulated as strong recommendations and 11 as weak—10 good practice points and two research only recommendations. Of the evidence-based recommendations, none were supported by high-quality evidence, one by moderate-quality evidence, nine by low-quality evidence, and 31 by very low-quality evidence. To support future research in UI, a list of research recommendations was provided. LIMITATIONS, REASONS FOR CAUTION Most additional diagnostic tests and interventions in couples with UI have not been subjected to robust evaluation. For a large proportion of these tests and treatments, evidence was very limited and of very low quality. More evidence is required, and the results of future studies may result in the current recommendations being revised. WIDER IMPLICATIONS OF THE FINDINGS The guideline provides clinicians with clear advice on best practice in the care of couples with UI, based on the best evidence currently available. In addition, a list of research recommendations is provided to stimulate further studies in the field. The full guideline and a patient leaflet are available in www.eshre.eu/guideline/UI. STUDY FUNDING/COMPETING INTEREST(S) The guideline was developed by ESHRE, who funded the guideline meetings, literature searches, and dissemination of the guideline in collaboration with the Monash University led Australian NHMRC Centre of Research Excellence in Women’s Health in Reproductive Life (CREWHIRL). The guideline group members did not receive any financial incentives; all work was provided voluntarily. D.R. reports honoraria from IBSA and Novo Nordisk. B.A. reports speakers’ fees from Merck, Gedeon Richter, Organon and Intas Pharma; is part of the advisory board for Organon Turkey and president of the Turkish Society of Reproductive Medicine. S.B. reports speakers’ fees from Merck, Organon, Ferring, the Ostetric and Gynaecological Society of Singapore and the Taiwanese Society for Reproductive Medicine; editor and contributing author, Reproductive Medicine for the MRCOG, Cambridge University Press; is part of the METAFOR and CAPE trials data monitoring committee. E.B. reports research grants from Roche diagnostics, Gedeon Richter and IBSA; speaker’s fees from Merck, Ferring, MSD, Roche Diagnostics, Gedeon Richter, IBSA; E.B. is also a part of an Advisory Board of Ferring Pharmaceuticals, MSD, Roche Diagnostics, IBSA, Merck, Abbott and Gedeon Richter. M.M. reports consulting fees from Mojo Fertility Ltd. R.J.N. reports research grant from Australian National Health and Medical Research Council (NHMRC); consulting fees from Flinders Fertility Adelaide, VinMec Hospital Hanoi Vietnam; speaker’s fees from Merck Australia, Cadilla Pharma India, Ferring Australia; chair clinical advisory committee Westmead Fertility and research institute MyDuc Hospital Vietnam. T.P. is a part of the Research Council of Finland and reports research grants from Roche Diagnostics, Novo Nordics and Sigrid Juselius foundation; consulting fees from Roche Diagnostics and organon; speaker’s fees from Gedeon Richter, Roche, Exeltis, Organon, Ferring and Korento patient organization; is a part of NFOG, AE-PCOS society and several Finnish associations. S.S.R. reports research grants from Roche Diagnostics, Organon, Theramex; consulting fees from Ferring Pharmaceuticals, MSD and Organon; speaker’s fees from Ferring Pharmaceuticals, MSD/Organon, Besins, Theramex, Gedeon Richter; travel support from Gedeon Richter; S.S.R. is part of the Data Safety Monitoring Board of TTRANSPORT and deputy of the ESHRE Special Interest Group on Safety and Quality in ART; stock or stock options from IVI Lisboa, Clínica de Reprodução assistida Lda; equipment/medical writing/gifts from Roche Diagnostics and Ferring Pharmaceuticals. S.K.S. reports speakers’ fees from Merck, Ferring, MSD, Pharmasure. HRV reports consulting and travel fees from Ferring Pharmaceuticals. The other authors have nothing to disclose. DISCLAIMER This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose. (Full disclaimer available at www.eshre.eu/guidelines.)

Study question: What is the optimal work-up to establish the diagnosis of unexplained infertility, based on the best available evidence in the literature? Summary answer: The ESHRE Guideline on Unexplained Infertility provides 35 recommendations on the diagnosis of unexplained infertility. What is known already? The diagnosis of unexplained infertility is made when no abnormalities of the female and/or male reproductive systems are clearly identified. UI is inevitably a diagnosis by exclusion, after “standard” investigations. However, a real standardization of the diagnostic work-up is still lacking. Study design, size, duration: The guideline was developed according to the structured methodology for the development of ESHRE guidelines. First, a group of experts formulated the key questions. Literature searches and assessments were then performed. Papers written in English and published up to 24 October 2022 were included in the review. Prior to publication, the guideline was reviewed by independent international reviewers. Participants/materials, setting, methods: Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. A stakeholders’ review was organized after the finalization of the draft. The revised version was approved by the guideline group and the ESHRE Executive Committee. Main results and the role of chance: This guideline aims to help clinicians in delivering the optimal care for couples with unexplained infertility. Since unexplained infertility is a diagnosis of exclusion, this lecture will focus on the diagnostic procedures that couples should/could go through during the infertility work-up, and will analyse the need for additional diagnostic tests to establish the diagnosis of unexplained infertility. The guideline has been in stakeholder review and is prepared for submission in 2023. Limitations, reasons for caution: Most diagnostic tests and interventions in couples with unexplained infertility are not well studied. For a large proportion of these tests, evidence was very limited and of very low quality. Further studies are definitely needed in this field, possibly providing reliable data for revisiting the current recommendations. Wider implications of the findings: Based on the best available evidence, the guideline provides clinicians with clear advice on how to optimize the diagnostic approach to couples with unexplained infertility. In addition, a list of research recommendations is included to prompt further studies in the field. Study funding/competing interest(s) The guideline was developed and funded by ESHRE, that covered expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not

Abstract Study question What are the test-retest reliability and the domain structures of the Dutch version of the PCOSQ and PCOSQOL in Dutch and Flemish women with PCOS? Summary answer The Dutch version of the PCOSQ and the PCOSQOL are reliable and can both be used to measure health-related quality of life (HRQoL) in PCOS. What is known already The polycystic ovary syndrome questionnaire (PCOSQ) is recommended to measure the quality of life in women with PCOS. The PCOSQ was developed in 1998 to complement generic health-related QoL instruments. The PCOSQ has been validated in Arabic, German, Chinese, and Swedish. Recent research suggested that the PCOSQ focuses on the physical impact of PCOS and that psychological, social, or environmental aspects are less represented. Therefore, the Polycystic Ovary Syndrome Quality Of Life Scale (PCOSQOL) was developed in 2018. Both questionnaires have not been validated in Dutch yet. Study design, size, duration A forward and backward translation was performed on the original English PCOSQ and PCOSQOL by two independent translators. PCOS patients were contacted with a request to complete both questionnaires (and some additional demographic questions) online in their home environment (T0). A test-retest design was applied to demonstrate stability over time by having all women complete the same questionnaires a second time (T1). Approval of the clinic’s Ethics Committee was obtained in both participating centres. Participants/materials, setting, methods Women of at least 18 years old, who were able to speak and write Dutch, and who were diagnosed with PCOS according to the Rotterdam criteria (ESHRE/ASRM, 2003) or according to the international evidence-based guideline for the assessment and management of PCOS (ESHRE, 2018) were eligible for the study. Women who were pregnant at T0 or T1 were excluded from the study. Participants were included between January and December 2021. Main results and the role of chance In total, 245 women were included in this study. The median age was 31 (19-54) years. For the PCOSQ, the Cronbach alpha statistic for the five domains ranged from 0.88 to 0.96 demonstrating good to excellent internal consistency. The Intra-class Correlation Coefficient (ICC) for the five domains was high to excellent ranging from 0.88 to 0.96. For the PCOSQOL, the Cronbach alpha ranged from 0.91 to 0.96 demonstrating excellent internal consistency. The ICC ranged from 0.91 to 0.96 for the four domains indicating excellent reliability. The factor analysis presented five domains of the PCOSQ and the original domain structure was partly confirmed. An extra domain for acne was included based on previous studies. Therefore, the Dutch version of the PCOSQ contained six domains: Weight, Body hair, Emotions, Infertility, Menstrual problems, and Acne. Based on the factor analysis, an extra domain was added to the original four domains of the PCOSQOL, which included items related to dealing with PCOS. Most women (70.6%) needed approximately 15 minutes to complete both questionnaires and had no preference for one of the two questionnaires (55.9%). Limitations, reasons for caution A limitation of our study could be that women with more PCOS complaints were more motivated to participate in this study. Therefore, potential selection bias should be taken into account. Wider implications of the findings The PCOSQ and PCOSQOL are disease-specific QoL measures for women with PCOS. The Dutch versions can be used in studies and in clinical settings (e.g. by nurses and midwives, counsellors, psychologists) to examine the impact of PCOS on QoL in Dutch and Flemish women. Trial registration number NA

Study question What are the current attitudes in Flemish adolescents aged 15-19 towards having children? Summary answer While the majority of adolescents want to have children, 25% have ambiguous feelings about having children and 10% indicate a wish to remain childless. What is known already In the past decades, a very positive attitude towards having children has been reported in young people. In the adult population, most people desire to have children or are already parents, but the group of people who choose to remain childfree is increasingly visible and vocal. The current generation of adolescents is more concerned about environmental impacts than previous generations. Study design, size, duration An anonymous online survey of multiple choice and open-ended questions was offered to adolescents in Flanders (Belgium). Forty – four schools in Flanders participated and 1700 adolescents completed the questionnaire from February 2022 to June 2022. We performed a qualitative analysis of answers in open ended questions. Participants/materials, setting, methods Adolescents aged 15 – 19 years old, attending the last two years of secondary school in Flanders (Belgium). Most pupils had the opportunity to complete the questionnaire during class, others chose to complete the questionnaire in their own free time. Main results and the role of chance The majority of pupils would like to have children (60.2%), a considerable proportion is still undecided (24.7%) and 10.8% report they do not want children. Significantly more boys than girls would like to have children (67% versus 61.7%, p < 0.01). Having a positive representation of children and the desire to build a family in the future are the most important reasons for wanting children. Adolescents who have ambiguous feelings or who do not want children are rather pragmatic in their decision-making. They may consider factors such as financial stability, career goals and personal development before deciding to have children. Other reasons for having an ambiguous or negative attitude towards parenthood reflect the sense of uncertainty in association with the current global situation and socio-political situation. Our data do not allow us to conclude whether the observed decline in the desire for parenthood is a temporary phenomenon closely linked to current events, or a more permanent one. Limitations, reasons for caution Participants were predominantly girls and attended general secondary education. The questionnaire has only been distributed in schools in Flanders and not in the entire country of Belgium due to administrative constraints. Pupils with a positive attitude towards having children may have been more likely to participate in the study. Wider implications of the findings Although reproductive intentions can change over the course of a lifetime, our results suggest that the future fertility rate may decline due to an increasing segment of voluntarily childfree people. A balance may be necessary between removing practical barriers toward parenthood, while acknowledging the legitimacy of other life plans. Trial registration number not applicable

Abstract Study question How do patients perceive the pre-IVF treatment communication by the nursing and midwifery team and how do they evaluate implemented optimization? Summary answer Patient satisfaction with the pre-IVF treatment communication by the nursing and midwifery team improved from 86% to 98% after implementation of standardized written patient information. What is known already Nurses are the main point of contact for patients undergoing medically assisted reproduction techniques (Applegarth et al., 2008). Morris (2001) suggested that infertility nurses could more specifically be involved in informative counselling in anticipation of the fertility treatment. Specific training for nurses and midwives would be required in order to achieve that central role in effective fertility counselling (Applegarth et al., 2012). However, little has been published in peer reviewed literature on how to assess and improve these pre-IVF treatment information sessions. Study design, size, duration The pre-IVF communication by the nurse/midwife was assessed by female patients with a self-developed questionnaire (cohort 1). The nursing and midwifery team was subsequently informed about the results of the questionnaire and efforts were undertaken to optimise future patient communication. Four years later, a follow-up questionnaire assessed patient satisfaction about the intervention (cohort 2). Each cohort comprised fifty patients and nurses and midwives were blinded for patient participation to the study. Participants/materials, setting, methods The study was performed at an academic fertility centre and was approved by the Investigational Review Board. Data were collected with SurveyMonkey (pre intervention) and REDCap (post intervention). A descriptive analysis of the cohorts and patient feedback was performed. The intervention consisted of (1) the optimization of patient information documents if needed (2) providing a training to the nursing and midwifery staff, and (3) a follow-up questionnaire in a second cohort of female fertility patients. Main results and the role of chance The first questionnaire revealed that overall, patients were satisfied with the informative counselling session in anticipation of the IVF treatment. However, some patients indicated that they received a lot of information at once and that specific information that was of relevance for the further treatment (e.g. oocyte pick-up) was sometimes missed. Also, the data showed that not all patients received the same information. Therefore, all information that patients needed during an IVF treatment was gathered into a patient binder. It was supplemented with a timeline of the whole IVF trajectory, QR codes to movies explaining the administration of medication, and answers to common patients’ questions. It was possible to individualize the content of the binder per patient. Ideally, patients received this binder before the informative counselling session so they could read the content in advance. The binder was developed by a member of the nursing and midwifery team and was reviewed by the medical, laboratory, and administrative staff. Then, the nursing and midwifery team was trained on the use of the patient binder. The follow-up questionnaire revealed that patient satisfaction with the pre-IVF treatment counselling was 98% after the optimization of patient documentation (compared to 86% before the optimization). Limitations, reasons for caution Eligible patients were recruited by the treating physician. As no records were kept of the number of solicited patients for this study, no assessment of the response rate is possible. The cohorts were self-selected and limited in size and could therefore not reflect the general patient population. Wider implications of the findings A patient questionnaire and follow-up is a useful tool for a centre specific assessment and improvement of pre-IVF nurse/midwife communication with patients. Clinics could make efforts to invest in complete and written information and ask colleagues of the nursing and midwifery team to be involved in its creation. Trial registration number NCT04420169

Abstract Study question How was the Logbook for the Nurses and Midwives Certification programme of the European Society of Human Reproduction and Embryology (ESHRE) developed? Summary answer The Logbook for the ESHRE Nurses and Midwives Certification programme, which questions 56 roles, was developed based on an extensive literature review and expert opinion. What is known already The ESHRE Executive Committee established the Nurses and Midwives Certification Committee (NMCC) in 2012. Since inception (2015), the certification programme has been delivered annually, with the exception of 2020 because of SARS-CoV-2. One-hundred-fourteen nurses/midwives have obtained ESHRE certification (passing rate=72%) and the programme is now accessible to nurses/midwives globally. The Certification program aims (i) to recognise the extended role of nurses/midwives delivering fertility care and (ii) to expand their theoretical background. The pre-requisites for certification are (i) being educated to a bachelor level of education and (ii) completing a practice based Logbook to demonstrate supervision of professional experience. Study design, size, duration Between 2012 and 2014, the NMCC completed a systematic literature search for papers relating to clinical, non-clinical and extended roles of nurses and midwives in fertility settings. In addition, the NMCC invited a larger expert panel of European senior nurses and midwives to a meeting to discuss their needs and preferences regarding the certification programme and to survey the diverse roles performed by nurses and midwives in their country. Participants/materials, setting, methods The NMCC comprised four nurses/midwives, one clinical embryologist, and one medical doctor (both in advisory capacity). The Medline database was searched by entering a search string in PubMed combining (MeSH) terms related to reproductive medicine and nursing or midwifery. Opinion and empirical papers relating to roles of nurses/midwives in fertility settings were included. The surveyed expert panel included twelve nurses/midwives, representing Belgium, Denmark, Finland, France, Norway, Slovenia, Sweden, Turkey, Ukraine, and the United Kingdom. Main results and the role of chance A total of 49 papers, of which 24 empirical papers, were identified with the search string (n = 47) and snowball strategy (n = 2). The papers originated from 13 countries spread across Asia, Oceania, Europe, and North America. All twelve European senior nurses and midwives responded to the survey. Finally, 56 different roles were included in the Logbook. Forty-four roles were performed by nurses/midwives working in fertility settings according to the surveyed expert panel (n = 18), the literature (n = 8), or both the surveyed expert panel and literature (n = 18). An additional twelve observations of laboratory procedures were added by the NMCC. Substantial variation in roles and responsibilities existed across the countries from which the evidence originated. Whereas a considerate proportion of roles were performed in at least five countries (n = 16/56), a minority of roles were only performed by nurses/midwives in some countries (n = 7/56). Eight specialist roles (e.g. embryo transfer) were performed independently by nurses/midwives in some countries, whilst in other countries, nurses/midwives merely had an assisting role. In addition to completing the Logbook, participants were expected to write two ethical cases according to a guideline, testifying to their ability to reflect as a senior nurse/midwife. From 2015, the content of the Logbook was further developed. Limitations, reasons for caution This abstract relates to the development and content of the Logbook and not the curriculum/educational material required for the theoretical exam of the Nurses and Midwives Certification programme. The NMCC continuously improves the Logbook and elements have been added and removed since its creation. Wider implications of the findings The review and survey illustrated the variation in roles and responsibilities of nurses/midwives across the studied countries, further highlighting the opportunity for professional development within fertility care. Further research is required to elicit the experience of certified nurses/midwives with the programme and its impact on their professional and personal development. Trial registration number Not applicable

ABSTRACT Research Question : Ovarian stimulation (OS) during in vitro fertilization (IVF) cycles involves close monitoring of estradiol (E2), progesterone (P4) and ultrasound measurements of follicle growth. In contrast to blood draws, sampling saliva is less invasive. Here, we present a blind validation of a novel saliva-based E2 and P4 assay performed in samples collected in independent IVF clinics. Design : Concurrent serum and saliva samples were collected from 324 patients at 6 large independent IVF laboratories. Saliva samples were frozen and run blinded. A further 18 patients had samples collected more frequently around the time of HCG trigger. Saliva samples were analyzed using an immunoassay developed with Salimetrics LLC. Results : In total, 652 pairs of saliva and serum E2 were evaluated, with correlation coefficients ranging from 0.68 to 0.91. In the European clinics a further 237 of saliva and serum P4 samples were evaluated however the correlations were generally poorer, ranging from -0.02 to 0.22. In the patients collected more frequently, 5 of 18 patients (27.8%) showed an immediate decrease in E2 after trigger. When P4 samples were assessed after trigger 8 of 18 (44.4%) showed a continued rise. Conclusions : Salivary E2 hormone testing correlates well to serum based assessment, while P4 values, around the time of trigger are not consistent from patient to patient.

Aim of the study Investigation of the correlation between serum estradiol (E2), salivary E2 and sonographic measurements of follicles in women undergoing controlled ovarian stimulation (COS) for IVF/ICSI. Methods This is a prospective study performed at the Department of Reproductive Medicine of Ghent University Hospital (Belgium) between November 2016 and January 2017 over a total of 40 patients. During routine COS, two-dimensional measurements of the follicles were performed using transvaginal ultrasound (TVUS) and E2 was measured in saliva and serum. A linear Mixed-Effects model (MIXED) was built, using SPSS Statistics 24. Results Statistical analysis shows a strong linear correlation between serum and salivary E2. For every single unit increase in serum E2 (+ 1 ng/L) the estimated saliva E2 concentration is expected to increase with 0.011 pg/mL (95% CI [0.009 - 0.01]). Strong linear correlations between both saliva and serum E2 and follicular dimensions were also found. For every millimetre increase in follicle diameter the estimated serum E2 concentration is expected to increase with 8.32 ng/L (95% CI [7, 10-9, 54]). For every millimetre increase in follicle diameter the estimated saliva level of E2 is expected to increase with 0.11 pg/mL (95% CI [0.09 - 0.13]). Conclusions A strong correlation between serum and salivary E2 concentrations was found. In addition, both are strongly correlated with the product of the number of follicles and their average diameter, measured by TVUS. More investigation needs to be done to find out if salivary E2 is an effective tool for monitoring IVF cycles.

Objective: This study aimed to gain an in-depth understanding of the experiences of genetic ties in intrafamily oocyte donation families. Background: Previous research has shown that most mothers have a good and stable relationship with their donor. Little is known about the meaning of the difference in genetic ties for parents who conceived through sister-to-sister oocyte donation. Methods: An Interpretative Phenomenological Analysis was performed and focused on both individual experiences and couple experiences with regard to genetic ties. Ten participants were recruited via an infertility clinic and took part in semistructured couple interviews. Results: Our analysis revealed that the donation was seen as a way to equal genetic parenthood. Participants struggled with this prevailing ideal of genetic parenthood and questioned the legitimacy of their motherhood. Several dynamics were identified when couples tried to deal with the imbalance in genetic ties: they acknowledged each other, convinced one another, or pushed away the difference in genetic ties. Couples also managed the presence of a genetic tie with the donor by negotiating the closeness in their family relationships. Conclusion: The lack of a full genetic tie remained a meaningful absence for some mothers and the way couples dealt with this varied. We plead that the option of post-donation care should be offered to support couples with the complexities they try to deal with.