Doctor–Couple Communication During Assisted Reproductive Technology Visits

D. Leone; L. Borghi; S. Del Negro; C. Becattini; E. Chelo; M. Costa; L. De Lauretis; A.P. Ferraretti; G. Giuffrida; C. Livi; A. Luehwink; R. Palermo; A. Revelli; G. Tomasi; F. Tomei; C. Filippini; E. Vegni


Hum Reprod. 2018;33(5):877-886. 

In This Article

Abstract and Introduction


Study Question: What are the characteristics of doctor–couple communication content during actual ART visits?

Summary Answer: Physicians were mainly focused on providing biomedical information, while communication content from couples had a 2-fold focus on providing biomedical information and on positive talk.

What is Known Already: Communication aspects in ART seem crucial for clinical decision-making, retention in care and critical conversations with couples due to low treatment success rates. However, no studies have been carried out on the actual interaction between the doctor and the couple in this context.

Study Design, Size, Duration: This observational study involved 28 clinicians and 160 patients referred to eight Italian ART clinics during a one-year recruitment period.

Participants/Materials, Setting, Methods: ART visits at eight Italian clinics were videotaped. The visits were coded using the Roter Interaction Analysis System (RIAS), particularly focusing on RIAS composite categories, verbal dominance and patient-centeredness score.

Main Results and the Role of Chance: A total of 85 visits were eligible for analysis (62% acceptance rate), involving 28 clinicians and 160 patients (including 75 couples). The average visit duration was 37 ± 17.7 min. The mean verbal dominance was 1.9 ± 0.86 (range: 0.72–5.74). Physicians mainly focused on providing biomedical information. Communication content from couples had a 2-fold focus on providing biomedical information and on positive talk. The mean of patient centeredness index (PCI) was 0.51 (SD = 0.28; range 0.08–1.77); visits in which the doctor was a woman or the treatment indication was for heterologous fertilization showed higher PCI scores. Overall, females accounted for 67% of all patient talk. Taking this imbalance into account as expected frequencies for each composite category, males reported significantly more utterances in almost all of the socioemotional categories.

Limitations, Reasons for Caution: These results are preliminary and observational and only regard Italy. Communication during visits may have been biased since the professionals who agreed to participate showed an interest in communication issues. Another limitation is a possible Hawthorne effect due to the fact that participants were aware of being videotaped.

Wider Implications of the Findings: Our study showed that ART physicians mainly adopted an informative model of communication and a more disease-oriented approach. Findings revealed the complexity of communication content during ART consultations, given its triadic characteristic in which the third party is also a patient; clinicians should be aware of this complex aspect and of the specific male and female perspectives to be taken into account. The results could be useful for training ART professionals.

Study Funding/Competing Interest(s): This study was possible thanks to an unconditional grant from Ferring Spa to the Department of Health Sciences, University of Milan. There are no competing interests to declare.


Over recent decades, the literature has underscored the importance of effective communication between doctors and patients as a central clinical function (Simpson et al., 1991). Good physician–patient communication includes effective relationship building, information gathering, understanding of the patient's perspective, information giving, involvement in the decision-making process, and taking patients' feelings, expectations and ideas into account (Stewart, 1995; Lipkin, 1996; Matusitz and Spear, 2014). Various studies have found that effective doctor–patient communication is associated with positive outcomes such as increased patient satisfaction and adherence, adjustment of expectations, self-regulation and coping (Stewart, 1995; Matusitz and Spear, 2014).

Assisted reproductive technology is a field in which treatment success rates are low, at around 30% per cycle (Ferraretti et al., 2013). Moreover, fertility treatment is known to be a source of stress for couples and may lead to discontinuation of treatment (Gameiro et al., 2012). Communication and relationship aspects could be crucial to clinical decision-making, retention in care and critical conversations with couples, such as delivering bad news. Some studies have found that poor communication and relationships with ART healthcare professionals could be a cause of dissatisfaction for patients and one of the reasons why couples may stop treatment or change clinic (Malin et al., 2001; Leite et al. 2005; Gameiro et al., 2012). Reasons for discontinuation due to communication have been: insufficient or poor explanations about fertility problems, poor management of psychological aspects (Gameiro et al., 2012), inadequate information provision and coordination of care (Haagen et al., 2008), lack of empathy and poor ability to handle psychological distress (Olivius et al., 2004), negative interactions with staff (Rajkhowa et al., 2006) and lack of patient-centered care (van Empel et al., 2011). In a qualitative study, Dancet et al. (2011) found that infertile patients considered the most important aspects of 'patient-centered infertility care' to be: staff attitudes and the relationship with staff, communication, patient involvement and privacy, and emotional support.

One aspect that makes communication particularly complex during ART visits is that the patient is the couple, which should be considered as a unit on the one hand, but on the other, is comprised of two separate individuals with different reactions and opinions (Lalos, 1999; Leone et al., 2017). Literature on triadic medical consultations has shown that triadic communication can be helpful but challenging (Laidsaar-Powell et al., 2013). However, to our knowledge, there are no studies exploring the role of the two members of the couple when they are both patients, as in the ART context.

Until now, literature has focused principally on the psychological effects of infertility treatments on couples (Newton et al., 1990; Cousineau and Domar, 2007) or on their satisfaction with infertility treatments (Malin et al., 2001; Groh and Wagner, 2005; Dancet et al., 2010; Huppelschoten et al., 2013) but little is known about how doctors manage actual ART conversations from a communication point of view. To our knowledge, the only one study exploring ART physicians communication in real-time evaluated communicative behaviors observed by a researcher during consultations and associated them with the patient's satisfaction at the end of the visit (Leite et al., 2005).

No studies are present in literature using video/audio recordings of actual ART consultations, although video is known to be the best way to study physician–patient communication and to understand what really happens during visits (Jordan and Henderson, 1995).

As a part of a larger study on the associations between physician–patient communication, patient satisfaction and patient engagement in the ART context, this study aimed to explore communication characteristics during ART visits, describing the main communication content from doctors and couples through the Roter Interaction Analysis System (RIAS), a well validated and widely used doctor–patient communication coding system (Roter and Larson, 2002). In greater detail, this study aimed: (i) to describe the communication content of doctors and couples during ART visits and the role of some demographic and clinical variables on doctor–couples communication, and (ii) to explore differences between the communication content of male and female patients.