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The attitudes of Dutch fertility specialists towards the addition of genetic testing in screening of tubal factor infertility
Sexual & Reproductive Healthcare 12 (2017) 123–127
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The attitudes of Dutch fertility specialists towards the addition of genetic testing in screening of tubal factor infertility Jelena Malogajski a, Marleen E. Jansen a,⇑, Sander Ouburg b, Elena Ambrosino a, Caroline B. Terwee c, Servaas A. Morré a,b a Institute for Public Health Genomics, Department of Genetics and Cell Biology, Research Institute GROW, Faculty of Health, Medicine & Life Sciences, University of Maastricht, Maastricht, The Netherlands b Laboratory of Immunogenetics, Department of Medical Microbiology and Infection Control, VU University Medical Center, Amsterdam, The Netherlands c Department of Epidemiology and Biostatistics and the EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
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Article history: Received 12 July 2016 Revised 31 January 2017 Accepted 3 April 2017
Keywords: Tubal factor infertility Chlamydia trachomatis Genetic test Screening Attitudes
a b s t r a c t Background: This study aims to identify elements perceived by Dutch fertility specialists as barriers and facilitators for the introduction of genetic testing, and their attitudes towards the use of genetic information. The genetic test would be implemented in routine screening for tubal pathology and identifies SNPs relevant for the immune response causing tubal pathology. Methods: Experienced reproductive specialists working in Dutch Academic Hospitals were interviewed. Based on the results of four interviews a questionnaire was developed and used to survey medical doctors in six out of eight Dutch Academic hospitals. Results: 60.4% (n = 91) stated that the addition of genetic markers to the Chlamydia trachomatis antibody test (CAT) in screening for tubal pathology would increase screening accuracy. 68.2% (n = 90) agreed they would require additional training on clinical genetics. Clinical utility (91.2%, n = 91) and costeffectiveness (95.6%, n = 91) were recognized by the respondents as important factors in gaining support for the new screening strategy. Conclusion: In summary, respondents showed a positive attitude towards the implementation of a genetic test combined with CAT for tubal factor infertility (TFI) screening. To gain their support the majority of respondents agreed that clinical utility, specifically cost-effectiveness, is an important factor. Comprehensive research about economic implications and utility regarding the introduction of genomic markers should be the next step in the implementation strategy. Furthermore, education and training would need to be developed and offered to fertility care professionals about genetic markers, their interpretation, and implications for clinical decision-making. Ó 2017 Elsevier B.V. All rights reserved.
Introduction The importance of genetic information in appropriate clinical management of diseases is increasing [1,2]. Using genetic information in routine clinical practice to provide high quality healthcare is one of the major hallmarks of personalized medicine. Advances in genetics have had clinical implications for the field of gynecology. Genetic testing found its first application in obstetrics/gynecology (OB/GYN) more than three decades ago with prenatal genetic screening for common birth defects during pregnancy [3]. More recently, preimplantation genetic screening has been introduced in the field of assisted reproductive medicine, aiming to improve ⇑ Corresponding author. E-mail address: [email protected] (M.E. Jansen). http://dx.doi.org/10.1016/j.srhc.2017.04.001 1877-5756/Ó 2017 Elsevier B.V. All rights reserved.
pregnancy rates in women older than 35 undergoing in vitro fertilization [4]. Additionally, genetic testing for the assessment of a patients risk for hereditary breast and ovarian cancer is routine in obstetric and gynecologic practice [5]. In recent years, genetic testing has been gaining importance in diagnosis of causes of infertility, for example through karyotype analysis [6]. However, to date genetic information has not been used for investigation of tubal pathology in the Netherlands. One in six couples worldwide are suffering from infertility [7]. In up to 30% of all cases infertility is attributed to tubal factors [8]. As much as 28–62% of tubal pathology can be linked to a previous Chlamydia infection [9]. Despite the fact that chlamydial infections are in most cases asymptomatic, and therefore go unnoticed and are not treated with antibiotics, almost half of the women without symptoms clear the infection without any
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treatment within a year [10]. However, other women are prone to persistent infections and consequent complications such as pelvic inflammatory disease, ectopic pregnancy and tubal factor infertility (TFI) [11]. Functional genetic variations, involved in the recognition of bacteria like Chlamydia and in the initiation of an adequate immune response, can contribute to higher or lower risk of Chlamydia induced TFI [12,13]. Identifying and correlating single nucleotide polymorphisms (SNPs) in pathogen recognizing receptor (PRR) genes with infection outcomes, offers an opportunity for the development of a new TFI screening strategy. Such an assay, which would be performed on human DNA isolated from a blood sample, is under development by an EU consortium. This consortium is called TubaTEST and is funded by the EU Eurostars Programme [14]. Adding genetic biomarkers to the screening for tubal pathology could be more accurate in identifying patients at low or high risk of having tubal pathology [15–17]. Currently, Chlamydia trachomatis antibody test (CAT) and hysterosalpingography (HSG) are the most commonly used screening tests for TFI in the Netherlands. They are followed by laparoscopy as the reference diagnostic. Sensitivity and specificity of the most accurate CATs are assessed at approximately 60% and 85–90% respectively [18]. For HSG, these numbers are 53% and 87% [19,20]. Therefore, there is room to increase the accuracy of TFI screening. Combining CAT testing with genetic testing early in the fertility work up could increase the accuracy of such screening and contribute to better triage of women for laparoscopy. Ultimately though, the ability of genomics to have an impact on clinical practice depends on clinicians’ knowledge and attitudes regarding genetic tests. Clinicians make decisions about ordering genetic tests and are responsible for interpreting and explaining the results to patients [21]. Measuring their experiences and attitudes towards the use of genetic tests is increasingly recognized as an important tool for understanding barriers and facilitators for the use of genetic information in diagnosis and treatment of diseases [22–25]. The aim of this study is therefore to identify elements perceived by Dutch gynecologists as barriers and facilitators for the introduction of genetic testing in the routine screening for TFI and to identify respondents’ attitudes towards the use of genetic information in the fertility work up. Methods The study was performed in two phases, qualitative interviews in the first phase, and quantitative questionnaires in the second. Within the first phase, experienced reproductive specialists working in four Dutch Academic Hospitals were interviewed. The results of these interviews were used to develop a questionnaire. This questionnaire was used in the second phase to survey medical doctors working at OB/GYN departments and providing fertility care in six (75%) Dutch Academic hospitals. Interviews Four semi-structured interviews were conducted with four reproductive specialists working in different Dutch academic hospitals in February and March 2013. The purpose of these interviews was twofold: establishing the status quo of fertility work up in the Netherlands, and gain insight into the barriers and facilitators of implementing a genetic test in this work up. The interviews explored: (a) the topic of infertility investigation in general, (b) current guidelines and practices in the screening for TFI, and (c) potential facilitators and barriers for broad implementation of genetic testing in the diagnosis of TFI. Three interviews were conducted face-to-face and one via Skype. Every reproductive special-
ist was interviewed individually. All the interviews were recorded and later transcribed. The transcripts of interviews were analyzed by coding them for recurring topics. The topics resulting from the interview analysis served as the basis to develop the questionnaire. Development of the questionnaire From the interviews, four themes were identified as relevant for the quantitative questionnaire. Each of the themes was further elaborated by defining important elements within them. The themes were: (1) the benefit of genetic testing for routine diagnostics, (2) the characteristics of the test, (3) patients preferences for non-invasive testing, and (4) possible issues around gynecologists’ roles and competences related to the introduction of genetic testing in routine fertility work up. For each theme, several relevant barriers and facilitators were identified from the interview data. The elements were then translated into statements to elicit participants’ attitudes through the perceived barriers and facilitators. For the purpose of the study, attitudes were understood as defined by Eagly and Chaiken as [26]: ‘‘psychological tendency that is expressed by evaluating a particular entity with some degree of favor or disfavor”. In order to assure content validity of the questionnaire the development followed an iterative process. The revisions of the questionnaire were based on multiple rounds of feedback from an experienced gynecologist and an epidemiologist, with expertise in the development and evaluation of health care outcome measures. The final draft of the questionnaire consisted of 10 questions and 14 statements, divided over three sections. In the first section we asked the respondents six questions about their demographics and level of professional experience. In the second section participants were asked four questions related to immunogenetic research of C. trachomatis and its possible implications for the clinical practice. The implications for clinical practice centered on clinical validity and clinical utility. Clinical validity includes analyses of test characteristics, such as the sensitivity and positive predictive value. Clinical utility takes the test a step further and focuses on the impact on care, through analyses such as costeffectiveness [27,28]. Finally, in the third section we asked the respondents to express their attitudes regarding the possible introduction of a genetic test (see Table 2 in Results). Respondents scored each statement by expressing how strongly they agreed or disagreed with it. Each statement had a 5-point Likert scale (agree disagree), and no opinion as response alternatives. Conducting the survey Data was gathered from Dutch Academic hospitals in Amsterdam, Groningen, Maastricht, Rotterdam, and Utrecht in the period May 2014 to July 2015. Visits were organized during department meetings in consultation with the head of the OB/GYN department at each hospital. The participation in the survey was voluntary and the questionnaire was distributed at the department. Only the response of medical doctors were included, regardless of their position, specialization & experience, and was completed on the spot to ensure an adequate response rate. Data analysis First, the demographics from section 1 were described followed by the answers to the questions on addressing genetic testing in TFI diagnosis in section 2. For section 3, statements and corresponding answers are shown in Table 2, representing the relative responses on the statements. Furthermore, the items in section 3
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The main characteristics of the participants are summarized in Table 1. Answering the question about their position at the department most respondents checked the box ‘‘Other” (37.4%), followed by resident physicians (25.5%). Respondents who checked the box ‘‘Other” were medical doctors that, for example, worked as IVF or fertility specialists at OB/GYN departments. Categorized to age groups, most participants were between 25 and 35 years old (51.1%), and 83.5% were female. 50.5% of the respondents had 0– 5 years of experience in their position, and 5.5% had over 20 years of experience.
9). In the bivariate analyses it was shown that position, years of experience, or hospital the respondents worked at did not significantly influence the scoring on the items (data not shown). 60.4% of the respondents found that genetic testing would increase the screening accuracy of TFI, but less than half agreed that genetic testing has a potential to lower the number of false negative and false positive results. When it comes to their opinion about the effect that genetic testing would have on the time to diagnosis, 45.1% of participants disagreed with the statement that the combination of genetic test and CAT, would in fact prolong this time. 26.4% expressed the attitude that the combination of tests would increase the time to diagnosis. 95.6% of the respondents would support the introduction of a genetic test in everyday clinical practice, where it is costeffective (statement 5), more than half of them (56.0%) also expressed that genome-based tests are too expensive (Table 2). Further, the respondents agreed or partially agreed that the clinical utility or clinical validity are the main measures of quality for a genetic test, 91.2% and 89.0% respectively (Table 2). 73.6% of participants stated that their patients have a preference for non-invasive testing. However, it appears that only 47.3% of respondents would honor their patients’ preferences. Although recognized in interviews as a potential barrier in acceptance of genetic testing, the diminished role of gynecologists in TFI screening in case of introduction of genetic testing was not identified as such by the majority of respondents. 16.5% of respondents found that the addition of genetic testing would diminish their role. Finally, 68.2% of the respondents stated that they would require additional training if a genetic test would be added to TFI screening (Table 2).
Implications for the clinical practice (questionnaire section 2)
Discussion and conclusion
64.8% of participants agreed that genetic information could be used in the routine screening of C. trachomatis induced infertility. 69.2% of the respondents believed that a combination of CAT and genetic markers will increase the sensitivity of infertility diagnosis. 61.5% would support the introduction of a genetic test in the screening for TFI. Regarding the location where the combination of tests (CAT and genetic markers test) should be performed, 80.2% of respondents agreed that the testing should be performed by the gynecologist in the hospital.
The present study was designed to investigate factors and elements, perceived by health professionals working in fertility care as barriers and facilitators for the introduction of genetic testing in screening for tubal pathology. Several statements have been identified as the major unifiers of participants’ attitudes towards genetic testing. Cost-effectiveness was indicated by 95.6% of participants as an important factor in gaining their support for the new addition to the screening strategy. These results are in accordance with the findings of an earlier study about physicians’ attitudes towards genetic testing for cancer susceptibility, which reported cost effectiveness and clinical utility as major concerns [29].
were analyzed using SPSS 22.0 (IBM) to perform recommended descriptive analyses for Likert scales, summarizing the mode and frequencies. Additionally, bivariate analyses were performed to study differences for scoring on each item between current position, years of experience, and hospital the respondents worked at. Results The questionnaire was answered by 91 medical doctors working at the OB/GYN departments of six Dutch Academic Hospitals. Out of the total number of participants seven worked at Academisch Medisch Centrum Amsterdam (AMC), 15 at Vrije Universiteit Medisch Centrum (VUMC), 18 at Universitair Medisch Centrum Groningen (UMCG), 19 at Maastricht Universitair Medisch Centrum (MUMC), 20 at Erasmus Medisch Centrum (Erasmus MC), and 12 at Universitair Medisch Centrum Utrecht (UMCU). Demographics (questionnaire section 1)
Attitudes (questionnaire section 3) For four statements the mode holds more than 50% of the responses (Table 2), which means that the score given most often (mode) was chosen over half of the respondents: established cost-effectiveness (statement 5); importance of clinical utility (statement 7); proven clinical validity and utility (statement 8); and patients’ preference for non-invasiveness of testing (statement
Practice and policy implications Genetic tests were considered too expensive by over half of the participants. This perception could be a serious barrier in referring patients to genetic testing. This finding also offers a relevant
Table 1 Number of respondents (% male) per hospital categorized to position (n = 91). Hospital
AMC, Amsterdam
VUMC, Amsterdam
UMCG, Groningen
MUMC, Maastricht
Erasmus MC, Rotterdam
UMCU, Utrecht
Total
Position Intern Resident physician Physician Gynecologist Other
1 1 0 2 3
1 2 0 4 8
2 6 1 5 4
5 7 2 3 2
(20.0) (0.0) (50.0) (66.7) (0.0)
1 (0.0) 4 (25.0) 0 (0.0) 3 (66.7) 12 (8.3)
0 4 0 3 5
(0.0) (25.0) (0.0) (33.3) (0.0)
10 (10.0) 24 (12.5) 3 (33.3) 20 (35.0) 34 (8.8)
14 (14.3) 3 (33.3) 1 (0.0) 1 (100) 19 (21.1)
7 (0.0) 9 (22.2) 4 (50.0) 0 (0.0) 20 (19.0)
5 (20.0) 3 (0.0) 2 (50.0) 2 (0.0) 12 (16.7)
46 (6.5) 22 (18.2) 18 (33.3) 5 (40.0) 91 (16.5)
(0.0) (0.0) (0.0) (0.0) (33.3)
Years of experience in current position 0–5 5 (0.0) 5–10 0 (0.0) 10–20 2 (50.0) 20 0 (0.0) Total 7 (14.3)
(0.0) (50.0) (0.0) (50.0) (0.0)
6 (0.0) 2 (50.0) 6 (16.7) 1 (100) 15 (20.0)
(0.0) (0.0) (0.0) (0.0) (25.0)
9 (0.0) 5 (0.0) 3 (33.3) 1 (0.0) 18 (5.6)
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Table 2 Each statement with the scores that were given with the related frequency and the mode (n = 91). Statement
Frequency (%) Agree
Partly agree
Neutral
Partly disagree
Disagree
No opinion
Total (n)
1
15 (16.5)
40 (44.0)
21 (23.1)
3 (3.3)
3 (3.3)
9 (9.9)
91
15 (16.5)
28 (30.8)
23 (25.3)
5 (5.5)
8 (8.8)
12 (13.2)
91
8 (8.8)
16 (17.6)
14 (15.4)
14 (15.4)
27 (29.7)
12 (13.2)
91
13 (14.3) 55 (60.4)
38 (41.8) 32 (35.2)
19 (20.9) 1 (1.1)
4 (4.4) 0 (0.0)
1 (1.1) 1 (1.1)
16 (17.6) 2 (2.2)
91 91
39 (42.9)
44 (48.4)
5 (5.5)
2 (2.2)
1 (1.1)
0 (0.0)
91
51 (56.0)
30 (33.0)
4 (4.4)
2 (2.2)
3 (3.3)
1 (1.1)
91
59 (64.8)
24 (26.4)
3 (3.3)
1 (1.1)
1 (1.1)
3 (3.3)
91
49 (53.8) 29 (31.9) 1 (1.1) 5 (5.5)
18 27 13 38
14 13 13 14
(15.4) (14.3) (14.3) (15.4)
1 (1.1) 7 (7.7) 23 (25.3) 20 (22.0)
1 (1.1) 1 (1.1) 30 (33.0) 4 (4.4)
8 (8.8) 14 (15.4) 10 (11.0) 9 (9.9)
91 91 90 90
7 (7.7)
8 (8.8)
16 (17.6)
22 (24.2)
33 (36.3)
4 (4.4)
90
21 (23.1)
41 (45.1)
12 (13.2)
5 (5.5)
7 (7.7)
4 (4.4)
90
2 3 4 5 6
7
8
9 10 11 12 13
14
Introducing genomic testing in the infertility investigation would increase the diagnostic accuracy of the diagnosis of tubal pathology Introducing genomic testing in the infertility investigation would lower the number of false negative/false positive results The genome-based companion diagnostic would increase the time to diagnosis of tubal pathology Genome-based tests are too expensive I would support the introduction of this genetic test in everyday clinical practice if it is cost-effective The main measure of a quality of a genetic test is the strength of association that determines the test’s ability to accurately and reliably identify or predict the disorder of interest (clinical validity) The main measure of quality of a genetic test is its improved health outcome, based on diagnosis and subsequent intervention (clinical utility) I would support the introduction of this genetic test in everyday clinical practice, prerequisite being proven clinical validity and utility My patients would have a preference for non-invasive testing My patients would prefer a genetic test instead of an HSG My patients would prefer a laparoscopy instead of a genetic test I would honor my patients’ preference for testing in the diagnosis of tubal patency If a clinical geneticist would be involved in the diagnosis of subfertility, I would feel that the role of the gynecologists would be diminished I would need training if a genetic test is added to the diagnostics of infertility
insight for focus on price concerns during the implementation phase. We found no difference in opinions between participants in different academic hospitals. Recent research shows however, that genetic testing may undeservedly be labeled as high-priced. A study reviewing the entire spectrum of economic evaluations associated with genetic testing used for guiding treatments and interventions, found no evidence that genetic testing is either inferior or superior in terms of cost-effectiveness to other medical interventions. Hatz et al. found that how the genetic test is used, rather than whether it was used, had the economic significance [30]. Both clinicians and policy-makers’ should be made aware of the actual cost and cost-effectiveness of genetic tests to address this issue. Furthermore, only through transparent cost-effectiveness studies can insurance coverage policies include genetic tests that have proven clinical utility [31]. When it came to the potential of chlamydial host genetic factors to improve the accuracy of the tubal pathology prediction, more than half of the participants were optimistic. Asked if the addition of genetic markers to the CAT in screening for tubal pathology could change the sensitivity of the diagnosis, more than two thirds of the respondents gave a positive answer. The majority of respondents believe that genetic testing should be offered and performed by gynecologists in the hospital. However, responding to the statement about the need for additional training if a genetic test was added to TFI screening, almost 70% of respondents expressed preferences for an additional training in clinical genetics prior to the introduction of the test. This finding is in accordance with an earlier study, which identified education and training designed to enable health-care professionals to interpret more complex genomic data as very important facilitating factors in the translation of innovative genomic tests into clinical practice [32]. The high percentage of participants expressing the need for additional training shows clinicians’ awareness of the advancements in genetic knowledge, and consequent changes in diagnostic
(19.8) (29.7) (14.3) (41.8)
and treatment strategies. This finding has clear policy and guideline implications. Providing clinicians solely with scientific evidence on the level of clinical validity and failing to consider their need for continuing medical education about genetic tests that show clinical utility would be inadequate. Limited evidence and knowledge of the impact of genetic information in the clinical management of patients with fertility issues is an important barrier to acceptance genetic testing. Policies addressing reforms of medical curriculum, should take this into consideration.
Study limitations Our study found no significant differences in attitudes between respondents based on their current position, years of experience in their current position, or the hospital they work at. Although the hospitals used in our relatively large sample (n = 91) were all Dutch academic hospitals, we managed to gather a pool of respondents with a wide range of years and levels of experience. Still, a limitation of our study is selection bias, because we did not randomly select hospitals, but purposely sampled academic hospitals. Generally, these hospitals are involved in more complex care than peripheral hospitals, which might have influenced the attitudes of the respondents. Furthermore, 34 of the respondents did not belong to the professional positions we defined, but in ‘Other’. Most of these respondents characterized their position as ‘IVF specialist’ or ‘fertility doctor’. The mixed positions in this category made our sample more heterogeneous, thus, it could have influenced the internal validity. Lastly, some of the respondents mentioned in the comment section of the questionnaire that they felt they did not have enough information or knowledge about the genetic test to respond to all the questions and statements. Even though this may have hampered them in responding, knowing that some healthcare professionals feel they have insufficient knowledge on genetic testing is valuable information.
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Research recommendations In conclusion, respondents showed a positive attitude towards the implementation of a genetic testing combined with CAT for TFI screening. Nevertheless, respondents also perceived some barriers for the implementation of such a test. To gain their support for the new screening strategy the majority of respondents agreed that cost-effectiveness is an important factor. Furthermore, clinical utility was recognized as the most important indicator of the quality of a genetic test, which translates into a clear need of evidence on outcomes such as health risks, effective education, and pilot studies. In addition to the justified expectations of the proven clinical utility, especially cost-effectiveness of the new screening strategy, perceived high costs associated with genetic testing poses the biggest barrier in acceptance of genetic testing in the diagnosis of TFI. In order to alleviate these concerns research about clinical utility, including the economic implications of the introduction of genomic markers in the routine fertility work up is needed. Funding This work was supported by European EuroTransBio Grant [Reference number 110012 ETC]. Conflict of interest Prof. Dr. S.A. Morré, fulltime employee of the VU University Medical Center Amsterdam is Founder (2011) and CEO of TubaScan Ltd., a spin-in company of the VU University Medical Center, Dept. of Medical Microbiology and Infection Prevention, Amsterdam, the Netherlands. One of the research lines inside TubaScan is on Female Reproductive Health, to which the work presented in this manuscript is linked to. Marleen E. Jansen PhD and Sander Ouburg PhD at the time of conducting this research had a partial appointment at TubaScan Ltd. Elena Ambrosino PhD, Jelena Malogajski PhD, and Caroline B. Terwee PhD declare that they have no conflict of interest. Acknowledgments We would like to thank all participants to our study from the Dutch Academic Hospitals we visited. References [1] Collins FS, McKusick VA. Implications of the human genome project for medical science. JAMA 2001;285(5):540–4. [2] Guttmacher AE, Porteous ME, McInerney JD. Educating health-care professionals about genetics and genomics. Nat Rev Genet 2007;8(2):151–7. [3] Lippman A. Prenatal genetic testing and screening: constructing needs and reinforcing inequities. Am JL Med 1991;17:15. [4] McGowan ML, Burant CJ, Moran R, Farrell R. Patient education and informed consent for preimplantation genetic diagnosis: health literacy for genetics and assisted reproductive technology. Genet Med 2009;11(9):640–5. [5] United States Preventive Services Task Force. Genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility: recommendation statement: United States preventive services task force. Int J Oncol 2004;3(1). [6] Foresta C, Ferlin A, Gianaroli L, Dallapiccola B. Guidelines for the appropriate use of genetic tests in infertile couples. Eur J Hum Genet: EJHG 2002;10 (5):303.
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The attitudes of Dutch fertility specialists towards the addition of genetic testing in screening of tubal factor infertility Jelena Malogajski a, Marleen E. Jansen a,⇑, Sander Ouburg b, Elena Ambrosino a, Caroline B. Terwee c, Servaas A. Morré a,b a Institute for Public Health Genomics, Department of Genetics and Cell Biology, Research Institute GROW, Faculty of Health, Medicine & Life Sciences, University of Maastricht, Maastricht, The Netherlands b Laboratory of Immunogenetics, Department of Medical Microbiology and Infection Control, VU University Medical Center, Amsterdam, The Netherlands c Department of Epidemiology and Biostatistics and the EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
a r t i c l e
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Article history: Received 12 July 2016 Revised 31 January 2017 Accepted 3 April 2017
Keywords: Tubal factor infertility Chlamydia trachomatis Genetic test Screening Attitudes
a b s t r a c t Background: This study aims to identify elements perceived by Dutch fertility specialists as barriers and facilitators for the introduction of genetic testing, and their attitudes towards the use of genetic information. The genetic test would be implemented in routine screening for tubal pathology and identifies SNPs relevant for the immune response causing tubal pathology. Methods: Experienced reproductive specialists working in Dutch Academic Hospitals were interviewed. Based on the results of four interviews a questionnaire was developed and used to survey medical doctors in six out of eight Dutch Academic hospitals. Results: 60.4% (n = 91) stated that the addition of genetic markers to the Chlamydia trachomatis antibody test (CAT) in screening for tubal pathology would increase screening accuracy. 68.2% (n = 90) agreed they would require additional training on clinical genetics. Clinical utility (91.2%, n = 91) and costeffectiveness (95.6%, n = 91) were recognized by the respondents as important factors in gaining support for the new screening strategy. Conclusion: In summary, respondents showed a positive attitude towards the implementation of a genetic test combined with CAT for tubal factor infertility (TFI) screening. To gain their support the majority of respondents agreed that clinical utility, specifically cost-effectiveness, is an important factor. Comprehensive research about economic implications and utility regarding the introduction of genomic markers should be the next step in the implementation strategy. Furthermore, education and training would need to be developed and offered to fertility care professionals about genetic markers, their interpretation, and implications for clinical decision-making. Ó 2017 Elsevier B.V. All rights reserved.
Introduction The importance of genetic information in appropriate clinical management of diseases is increasing [1,2]. Using genetic information in routine clinical practice to provide high quality healthcare is one of the major hallmarks of personalized medicine. Advances in genetics have had clinical implications for the field of gynecology. Genetic testing found its first application in obstetrics/gynecology (OB/GYN) more than three decades ago with prenatal genetic screening for common birth defects during pregnancy [3]. More recently, preimplantation genetic screening has been introduced in the field of assisted reproductive medicine, aiming to improve ⇑ Corresponding author. E-mail address: [email protected] (M.E. Jansen). http://dx.doi.org/10.1016/j.srhc.2017.04.001 1877-5756/Ó 2017 Elsevier B.V. All rights reserved.
pregnancy rates in women older than 35 undergoing in vitro fertilization [4]. Additionally, genetic testing for the assessment of a patients risk for hereditary breast and ovarian cancer is routine in obstetric and gynecologic practice [5]. In recent years, genetic testing has been gaining importance in diagnosis of causes of infertility, for example through karyotype analysis [6]. However, to date genetic information has not been used for investigation of tubal pathology in the Netherlands. One in six couples worldwide are suffering from infertility [7]. In up to 30% of all cases infertility is attributed to tubal factors [8]. As much as 28–62% of tubal pathology can be linked to a previous Chlamydia infection [9]. Despite the fact that chlamydial infections are in most cases asymptomatic, and therefore go unnoticed and are not treated with antibiotics, almost half of the women without symptoms clear the infection without any
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treatment within a year [10]. However, other women are prone to persistent infections and consequent complications such as pelvic inflammatory disease, ectopic pregnancy and tubal factor infertility (TFI) [11]. Functional genetic variations, involved in the recognition of bacteria like Chlamydia and in the initiation of an adequate immune response, can contribute to higher or lower risk of Chlamydia induced TFI [12,13]. Identifying and correlating single nucleotide polymorphisms (SNPs) in pathogen recognizing receptor (PRR) genes with infection outcomes, offers an opportunity for the development of a new TFI screening strategy. Such an assay, which would be performed on human DNA isolated from a blood sample, is under development by an EU consortium. This consortium is called TubaTEST and is funded by the EU Eurostars Programme [14]. Adding genetic biomarkers to the screening for tubal pathology could be more accurate in identifying patients at low or high risk of having tubal pathology [15–17]. Currently, Chlamydia trachomatis antibody test (CAT) and hysterosalpingography (HSG) are the most commonly used screening tests for TFI in the Netherlands. They are followed by laparoscopy as the reference diagnostic. Sensitivity and specificity of the most accurate CATs are assessed at approximately 60% and 85–90% respectively [18]. For HSG, these numbers are 53% and 87% [19,20]. Therefore, there is room to increase the accuracy of TFI screening. Combining CAT testing with genetic testing early in the fertility work up could increase the accuracy of such screening and contribute to better triage of women for laparoscopy. Ultimately though, the ability of genomics to have an impact on clinical practice depends on clinicians’ knowledge and attitudes regarding genetic tests. Clinicians make decisions about ordering genetic tests and are responsible for interpreting and explaining the results to patients [21]. Measuring their experiences and attitudes towards the use of genetic tests is increasingly recognized as an important tool for understanding barriers and facilitators for the use of genetic information in diagnosis and treatment of diseases [22–25]. The aim of this study is therefore to identify elements perceived by Dutch gynecologists as barriers and facilitators for the introduction of genetic testing in the routine screening for TFI and to identify respondents’ attitudes towards the use of genetic information in the fertility work up. Methods The study was performed in two phases, qualitative interviews in the first phase, and quantitative questionnaires in the second. Within the first phase, experienced reproductive specialists working in four Dutch Academic Hospitals were interviewed. The results of these interviews were used to develop a questionnaire. This questionnaire was used in the second phase to survey medical doctors working at OB/GYN departments and providing fertility care in six (75%) Dutch Academic hospitals. Interviews Four semi-structured interviews were conducted with four reproductive specialists working in different Dutch academic hospitals in February and March 2013. The purpose of these interviews was twofold: establishing the status quo of fertility work up in the Netherlands, and gain insight into the barriers and facilitators of implementing a genetic test in this work up. The interviews explored: (a) the topic of infertility investigation in general, (b) current guidelines and practices in the screening for TFI, and (c) potential facilitators and barriers for broad implementation of genetic testing in the diagnosis of TFI. Three interviews were conducted face-to-face and one via Skype. Every reproductive special-
ist was interviewed individually. All the interviews were recorded and later transcribed. The transcripts of interviews were analyzed by coding them for recurring topics. The topics resulting from the interview analysis served as the basis to develop the questionnaire. Development of the questionnaire From the interviews, four themes were identified as relevant for the quantitative questionnaire. Each of the themes was further elaborated by defining important elements within them. The themes were: (1) the benefit of genetic testing for routine diagnostics, (2) the characteristics of the test, (3) patients preferences for non-invasive testing, and (4) possible issues around gynecologists’ roles and competences related to the introduction of genetic testing in routine fertility work up. For each theme, several relevant barriers and facilitators were identified from the interview data. The elements were then translated into statements to elicit participants’ attitudes through the perceived barriers and facilitators. For the purpose of the study, attitudes were understood as defined by Eagly and Chaiken as [26]: ‘‘psychological tendency that is expressed by evaluating a particular entity with some degree of favor or disfavor”. In order to assure content validity of the questionnaire the development followed an iterative process. The revisions of the questionnaire were based on multiple rounds of feedback from an experienced gynecologist and an epidemiologist, with expertise in the development and evaluation of health care outcome measures. The final draft of the questionnaire consisted of 10 questions and 14 statements, divided over three sections. In the first section we asked the respondents six questions about their demographics and level of professional experience. In the second section participants were asked four questions related to immunogenetic research of C. trachomatis and its possible implications for the clinical practice. The implications for clinical practice centered on clinical validity and clinical utility. Clinical validity includes analyses of test characteristics, such as the sensitivity and positive predictive value. Clinical utility takes the test a step further and focuses on the impact on care, through analyses such as costeffectiveness [27,28]. Finally, in the third section we asked the respondents to express their attitudes regarding the possible introduction of a genetic test (see Table 2 in Results). Respondents scored each statement by expressing how strongly they agreed or disagreed with it. Each statement had a 5-point Likert scale (agree disagree), and no opinion as response alternatives. Conducting the survey Data was gathered from Dutch Academic hospitals in Amsterdam, Groningen, Maastricht, Rotterdam, and Utrecht in the period May 2014 to July 2015. Visits were organized during department meetings in consultation with the head of the OB/GYN department at each hospital. The participation in the survey was voluntary and the questionnaire was distributed at the department. Only the response of medical doctors were included, regardless of their position, specialization & experience, and was completed on the spot to ensure an adequate response rate. Data analysis First, the demographics from section 1 were described followed by the answers to the questions on addressing genetic testing in TFI diagnosis in section 2. For section 3, statements and corresponding answers are shown in Table 2, representing the relative responses on the statements. Furthermore, the items in section 3
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The main characteristics of the participants are summarized in Table 1. Answering the question about their position at the department most respondents checked the box ‘‘Other” (37.4%), followed by resident physicians (25.5%). Respondents who checked the box ‘‘Other” were medical doctors that, for example, worked as IVF or fertility specialists at OB/GYN departments. Categorized to age groups, most participants were between 25 and 35 years old (51.1%), and 83.5% were female. 50.5% of the respondents had 0– 5 years of experience in their position, and 5.5% had over 20 years of experience.
9). In the bivariate analyses it was shown that position, years of experience, or hospital the respondents worked at did not significantly influence the scoring on the items (data not shown). 60.4% of the respondents found that genetic testing would increase the screening accuracy of TFI, but less than half agreed that genetic testing has a potential to lower the number of false negative and false positive results. When it comes to their opinion about the effect that genetic testing would have on the time to diagnosis, 45.1% of participants disagreed with the statement that the combination of genetic test and CAT, would in fact prolong this time. 26.4% expressed the attitude that the combination of tests would increase the time to diagnosis. 95.6% of the respondents would support the introduction of a genetic test in everyday clinical practice, where it is costeffective (statement 5), more than half of them (56.0%) also expressed that genome-based tests are too expensive (Table 2). Further, the respondents agreed or partially agreed that the clinical utility or clinical validity are the main measures of quality for a genetic test, 91.2% and 89.0% respectively (Table 2). 73.6% of participants stated that their patients have a preference for non-invasive testing. However, it appears that only 47.3% of respondents would honor their patients’ preferences. Although recognized in interviews as a potential barrier in acceptance of genetic testing, the diminished role of gynecologists in TFI screening in case of introduction of genetic testing was not identified as such by the majority of respondents. 16.5% of respondents found that the addition of genetic testing would diminish their role. Finally, 68.2% of the respondents stated that they would require additional training if a genetic test would be added to TFI screening (Table 2).
Implications for the clinical practice (questionnaire section 2)
Discussion and conclusion
64.8% of participants agreed that genetic information could be used in the routine screening of C. trachomatis induced infertility. 69.2% of the respondents believed that a combination of CAT and genetic markers will increase the sensitivity of infertility diagnosis. 61.5% would support the introduction of a genetic test in the screening for TFI. Regarding the location where the combination of tests (CAT and genetic markers test) should be performed, 80.2% of respondents agreed that the testing should be performed by the gynecologist in the hospital.
The present study was designed to investigate factors and elements, perceived by health professionals working in fertility care as barriers and facilitators for the introduction of genetic testing in screening for tubal pathology. Several statements have been identified as the major unifiers of participants’ attitudes towards genetic testing. Cost-effectiveness was indicated by 95.6% of participants as an important factor in gaining their support for the new addition to the screening strategy. These results are in accordance with the findings of an earlier study about physicians’ attitudes towards genetic testing for cancer susceptibility, which reported cost effectiveness and clinical utility as major concerns [29].
were analyzed using SPSS 22.0 (IBM) to perform recommended descriptive analyses for Likert scales, summarizing the mode and frequencies. Additionally, bivariate analyses were performed to study differences for scoring on each item between current position, years of experience, and hospital the respondents worked at. Results The questionnaire was answered by 91 medical doctors working at the OB/GYN departments of six Dutch Academic Hospitals. Out of the total number of participants seven worked at Academisch Medisch Centrum Amsterdam (AMC), 15 at Vrije Universiteit Medisch Centrum (VUMC), 18 at Universitair Medisch Centrum Groningen (UMCG), 19 at Maastricht Universitair Medisch Centrum (MUMC), 20 at Erasmus Medisch Centrum (Erasmus MC), and 12 at Universitair Medisch Centrum Utrecht (UMCU). Demographics (questionnaire section 1)
Attitudes (questionnaire section 3) For four statements the mode holds more than 50% of the responses (Table 2), which means that the score given most often (mode) was chosen over half of the respondents: established cost-effectiveness (statement 5); importance of clinical utility (statement 7); proven clinical validity and utility (statement 8); and patients’ preference for non-invasiveness of testing (statement
Practice and policy implications Genetic tests were considered too expensive by over half of the participants. This perception could be a serious barrier in referring patients to genetic testing. This finding also offers a relevant
Table 1 Number of respondents (% male) per hospital categorized to position (n = 91). Hospital
AMC, Amsterdam
VUMC, Amsterdam
UMCG, Groningen
MUMC, Maastricht
Erasmus MC, Rotterdam
UMCU, Utrecht
Total
Position Intern Resident physician Physician Gynecologist Other
1 1 0 2 3
1 2 0 4 8
2 6 1 5 4
5 7 2 3 2
(20.0) (0.0) (50.0) (66.7) (0.0)
1 (0.0) 4 (25.0) 0 (0.0) 3 (66.7) 12 (8.3)
0 4 0 3 5
(0.0) (25.0) (0.0) (33.3) (0.0)
10 (10.0) 24 (12.5) 3 (33.3) 20 (35.0) 34 (8.8)
14 (14.3) 3 (33.3) 1 (0.0) 1 (100) 19 (21.1)
7 (0.0) 9 (22.2) 4 (50.0) 0 (0.0) 20 (19.0)
5 (20.0) 3 (0.0) 2 (50.0) 2 (0.0) 12 (16.7)
46 (6.5) 22 (18.2) 18 (33.3) 5 (40.0) 91 (16.5)
(0.0) (0.0) (0.0) (0.0) (33.3)
Years of experience in current position 0–5 5 (0.0) 5–10 0 (0.0) 10–20 2 (50.0) 20 0 (0.0) Total 7 (14.3)
(0.0) (50.0) (0.0) (50.0) (0.0)
6 (0.0) 2 (50.0) 6 (16.7) 1 (100) 15 (20.0)
(0.0) (0.0) (0.0) (0.0) (25.0)
9 (0.0) 5 (0.0) 3 (33.3) 1 (0.0) 18 (5.6)
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Table 2 Each statement with the scores that were given with the related frequency and the mode (n = 91). Statement
Frequency (%) Agree
Partly agree
Neutral
Partly disagree
Disagree
No opinion
Total (n)
1
15 (16.5)
40 (44.0)
21 (23.1)
3 (3.3)
3 (3.3)
9 (9.9)
91
15 (16.5)
28 (30.8)
23 (25.3)
5 (5.5)
8 (8.8)
12 (13.2)
91
8 (8.8)
16 (17.6)
14 (15.4)
14 (15.4)
27 (29.7)
12 (13.2)
91
13 (14.3) 55 (60.4)
38 (41.8) 32 (35.2)
19 (20.9) 1 (1.1)
4 (4.4) 0 (0.0)
1 (1.1) 1 (1.1)
16 (17.6) 2 (2.2)
91 91
39 (42.9)
44 (48.4)
5 (5.5)
2 (2.2)
1 (1.1)
0 (0.0)
91
51 (56.0)
30 (33.0)
4 (4.4)
2 (2.2)
3 (3.3)
1 (1.1)
91
59 (64.8)
24 (26.4)
3 (3.3)
1 (1.1)
1 (1.1)
3 (3.3)
91
49 (53.8) 29 (31.9) 1 (1.1) 5 (5.5)
18 27 13 38
14 13 13 14
(15.4) (14.3) (14.3) (15.4)
1 (1.1) 7 (7.7) 23 (25.3) 20 (22.0)
1 (1.1) 1 (1.1) 30 (33.0) 4 (4.4)
8 (8.8) 14 (15.4) 10 (11.0) 9 (9.9)
91 91 90 90
7 (7.7)
8 (8.8)
16 (17.6)
22 (24.2)
33 (36.3)
4 (4.4)
90
21 (23.1)
41 (45.1)
12 (13.2)
5 (5.5)
7 (7.7)
4 (4.4)
90
2 3 4 5 6
7
8
9 10 11 12 13
14
Introducing genomic testing in the infertility investigation would increase the diagnostic accuracy of the diagnosis of tubal pathology Introducing genomic testing in the infertility investigation would lower the number of false negative/false positive results The genome-based companion diagnostic would increase the time to diagnosis of tubal pathology Genome-based tests are too expensive I would support the introduction of this genetic test in everyday clinical practice if it is cost-effective The main measure of a quality of a genetic test is the strength of association that determines the test’s ability to accurately and reliably identify or predict the disorder of interest (clinical validity) The main measure of quality of a genetic test is its improved health outcome, based on diagnosis and subsequent intervention (clinical utility) I would support the introduction of this genetic test in everyday clinical practice, prerequisite being proven clinical validity and utility My patients would have a preference for non-invasive testing My patients would prefer a genetic test instead of an HSG My patients would prefer a laparoscopy instead of a genetic test I would honor my patients’ preference for testing in the diagnosis of tubal patency If a clinical geneticist would be involved in the diagnosis of subfertility, I would feel that the role of the gynecologists would be diminished I would need training if a genetic test is added to the diagnostics of infertility
insight for focus on price concerns during the implementation phase. We found no difference in opinions between participants in different academic hospitals. Recent research shows however, that genetic testing may undeservedly be labeled as high-priced. A study reviewing the entire spectrum of economic evaluations associated with genetic testing used for guiding treatments and interventions, found no evidence that genetic testing is either inferior or superior in terms of cost-effectiveness to other medical interventions. Hatz et al. found that how the genetic test is used, rather than whether it was used, had the economic significance [30]. Both clinicians and policy-makers’ should be made aware of the actual cost and cost-effectiveness of genetic tests to address this issue. Furthermore, only through transparent cost-effectiveness studies can insurance coverage policies include genetic tests that have proven clinical utility [31]. When it came to the potential of chlamydial host genetic factors to improve the accuracy of the tubal pathology prediction, more than half of the participants were optimistic. Asked if the addition of genetic markers to the CAT in screening for tubal pathology could change the sensitivity of the diagnosis, more than two thirds of the respondents gave a positive answer. The majority of respondents believe that genetic testing should be offered and performed by gynecologists in the hospital. However, responding to the statement about the need for additional training if a genetic test was added to TFI screening, almost 70% of respondents expressed preferences for an additional training in clinical genetics prior to the introduction of the test. This finding is in accordance with an earlier study, which identified education and training designed to enable health-care professionals to interpret more complex genomic data as very important facilitating factors in the translation of innovative genomic tests into clinical practice [32]. The high percentage of participants expressing the need for additional training shows clinicians’ awareness of the advancements in genetic knowledge, and consequent changes in diagnostic
(19.8) (29.7) (14.3) (41.8)
and treatment strategies. This finding has clear policy and guideline implications. Providing clinicians solely with scientific evidence on the level of clinical validity and failing to consider their need for continuing medical education about genetic tests that show clinical utility would be inadequate. Limited evidence and knowledge of the impact of genetic information in the clinical management of patients with fertility issues is an important barrier to acceptance genetic testing. Policies addressing reforms of medical curriculum, should take this into consideration.
Study limitations Our study found no significant differences in attitudes between respondents based on their current position, years of experience in their current position, or the hospital they work at. Although the hospitals used in our relatively large sample (n = 91) were all Dutch academic hospitals, we managed to gather a pool of respondents with a wide range of years and levels of experience. Still, a limitation of our study is selection bias, because we did not randomly select hospitals, but purposely sampled academic hospitals. Generally, these hospitals are involved in more complex care than peripheral hospitals, which might have influenced the attitudes of the respondents. Furthermore, 34 of the respondents did not belong to the professional positions we defined, but in ‘Other’. Most of these respondents characterized their position as ‘IVF specialist’ or ‘fertility doctor’. The mixed positions in this category made our sample more heterogeneous, thus, it could have influenced the internal validity. Lastly, some of the respondents mentioned in the comment section of the questionnaire that they felt they did not have enough information or knowledge about the genetic test to respond to all the questions and statements. Even though this may have hampered them in responding, knowing that some healthcare professionals feel they have insufficient knowledge on genetic testing is valuable information.
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Research recommendations In conclusion, respondents showed a positive attitude towards the implementation of a genetic testing combined with CAT for TFI screening. Nevertheless, respondents also perceived some barriers for the implementation of such a test. To gain their support for the new screening strategy the majority of respondents agreed that cost-effectiveness is an important factor. Furthermore, clinical utility was recognized as the most important indicator of the quality of a genetic test, which translates into a clear need of evidence on outcomes such as health risks, effective education, and pilot studies. In addition to the justified expectations of the proven clinical utility, especially cost-effectiveness of the new screening strategy, perceived high costs associated with genetic testing poses the biggest barrier in acceptance of genetic testing in the diagnosis of TFI. In order to alleviate these concerns research about clinical utility, including the economic implications of the introduction of genomic markers in the routine fertility work up is needed. Funding This work was supported by European EuroTransBio Grant [Reference number 110012 ETC]. Conflict of interest Prof. Dr. S.A. Morré, fulltime employee of the VU University Medical Center Amsterdam is Founder (2011) and CEO of TubaScan Ltd., a spin-in company of the VU University Medical Center, Dept. of Medical Microbiology and Infection Prevention, Amsterdam, the Netherlands. One of the research lines inside TubaScan is on Female Reproductive Health, to which the work presented in this manuscript is linked to. Marleen E. Jansen PhD and Sander Ouburg PhD at the time of conducting this research had a partial appointment at TubaScan Ltd. Elena Ambrosino PhD, Jelena Malogajski PhD, and Caroline B. Terwee PhD declare that they have no conflict of interest. Acknowledgments We would like to thank all participants to our study from the Dutch Academic Hospitals we visited. References [1] Collins FS, McKusick VA. Implications of the human genome project for medical science. JAMA 2001;285(5):540–4. [2] Guttmacher AE, Porteous ME, McInerney JD. Educating health-care professionals about genetics and genomics. Nat Rev Genet 2007;8(2):151–7. [3] Lippman A. Prenatal genetic testing and screening: constructing needs and reinforcing inequities. Am JL Med 1991;17:15. [4] McGowan ML, Burant CJ, Moran R, Farrell R. Patient education and informed consent for preimplantation genetic diagnosis: health literacy for genetics and assisted reproductive technology. Genet Med 2009;11(9):640–5. [5] United States Preventive Services Task Force. Genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility: recommendation statement: United States preventive services task force. Int J Oncol 2004;3(1). [6] Foresta C, Ferlin A, Gianaroli L, Dallapiccola B. Guidelines for the appropriate use of genetic tests in infertile couples. Eur J Hum Genet: EJHG 2002;10 (5):303.
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