Parents' experiencees of life after medicalised conception: A systematic review and thematic meta-synthesis

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As the impact of MAC has been linked to increased pregnancy-specific anxiety and parenting difficulties, this review aimed to explore parental experiences of pregnancy and early parenting following MAC, identifying their psychological, social and health needs. Method: Five databases were searched systematically. Identified articles were screened for eligibility. Twenty qualitative studies met inclusion criteria and results were analysed using thematic synthesis. The Critical Appraisal Skills checklist was employed to appraise methodological quality. Results: The findings were synthesised into three main themes: 1) The vulnerable parent: fear, doubt, uncertainty, 2) the stark realisation of the parental dream, 3) psychosocial needs and support. Parents lacked a sense of safety during pregnancy and acted protectively, both antenatally and postnatally . Identity transition was complex and non-linear, influenced by sociocultural context. Conclusions: Considerable unmet psychosocial needs were identified with a need for consistent, holistic care, integrating psychological services. Pregnancy parenting antenatal postnatal assisted reproduction Figures Figure 1 Figure 2 Introduction Medicalised conception (MAC) assists individuals in achieving pregnancy. MAC is an umbrella term which encompasses many different types of treatment including In-Vitro Fertilisation (IVF), Intracytoplasmic Sperm Injection (ICSI), Donor Insemination and Gamete Intrafallopian Transfer 1 . Most individuals who seek MAC are heterosexual couples with fertility challenges (96%) 1 . However, family structures are changing with an increase in same-sex couples and individuals without a partner pursuing MAC. The prevalence of MAC is rising year on year, for example, with IVF birth rates three times higher in the United Kingdom (UK) when compared to 1991 1 . In 2019, 2.1% of all births in the United States resulted from MAC 2 , similar statistics are seen in many other countries 3,4 . MAC is often not a singular event but a repeated cumulative process 5 . The physical and emotional demands of MAC are well documented in the literature, impacting on subsequent antenatal and postnatal experiences when conception is achieved 5-7 . A previous quantitative 7 and mixed method systematic review 5 described the evidence base as “emergent” 5 (p.411) . Consistent reports of increased pregnancy-specific anxiety 5,7 and preoccupation regarding the health and safety of the developing baby have been identified 5 . Internationally, there is a growing body of qualitative literature exploring pregnancy and parenting following MAC. A qualitative systematic review of seven studies conducted by Maehara et al. (2021) 8 explored the antenatal experiences of individuals who conceived via MAC. They confirmed fears regarding pregnancy loss and suggested individuals avoided developing a maternal identity to protect themselves against anticipated disappointment. Furthermore, they found changes to lifestyle 9,10 , an increased need for reassurance 6 , often viewing themselves differently to spontaneously conceiving mothers 11,12 . Despite this, in the UK, fertility treatment is not recognised as a risk factor for adverse perinatal mental health 13 , with parents recommended to receive routine antenatal and postnatal care. Understanding the psychological, social and healthcare needs of this population is essential to ensure services appropriately meet the emotional care needs of parents following MAC. The current literature 7,8 focuses predominately on the antenatal experiences of the gestating partner experience. In addition, there is also evidence of hypervigilance and feelings of exclusion amongst fathers following MAC 14 . The current review is necessary to expand understanding regarding the transition to parenthood, incorporating postnatal experiences. To allow a more holistic examination of the qualitative literature, this systematic review aimed to synthesise and appraise the qualitative literature examining both parents’ experiences of pregnancy and parenthood, following MAC. This review also aimed to extract the psychological, social, and healthcare needs of parents, identifying clinical recommendations to enhance future service provision. Methods A systematic review and meta-synthesis, informed by the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines 15 was conducted. The protocol was registered with PROSPERO on 2/08/2021 (REF: CRD42021269664). Search strategy The Sample, Phenomenon of Interest, Design, Evaluation, Research type (SPIDER) 16 framework for qualitative synthesis was used to develop a systematic search strategy (see Table 1). Electronic searches were conducted in five databases: MEDLINE, PsycINFO, EMBASE, CINAHL and Web of Science in April 2021, with no restrictions on publication date. Due to the multi-disciplinary nature of MAC, database selection ensured study detection from psychological, medical and nursing literature. Search terms were informed by the titles and abstracts of key papers and reviews. Truncation and Boolean operators were utilised to combine searches for individual databases. Table 1: Search strategy and terms SPIDER framework Search terms used 1 Sample (S) Pregnan* OR Antenatal* OR Postnatal OR Postpartum OR Early paren*OR Transition Parent* OR Mother* OR women OR woman OR partner* OR Lone paren* OR same sex couples OR Same sex parent* OR couples OR infertile couples Subfertility OR infertility OR genetic pre-implantation OR blood borne a – c connected with AND 2 Phenomenon of Interest (PI) Assisted reproductive techn* OR Assisted reproductive treatment* Assisted reproduction OR ART OR Medicalised conception OR Medically assisted conception OR MAC OR Medicalized conception OR In Vitro Fertilisation OR In Vitro Fertilization OR IVF OR Intracytoplasmic Sperm Injection OR ICSI or Assisted conception OR Fertility treatmen* 3 Design (D) questionnaire* OR survey* OR interview* OR focus group* OR case stud* OR observ* 4 Evaluation/outcome (E) Psychological outcomes: Psycho* OR Emotional well-being OR Emotional adaptation OR anxiety OR pregnancy specific anxiety OR self-esteem OR self-confidence OR depression OR low mood OR stress OR trauma OR adjustment OR attachment Social Outcomes: Marital discord OR marital satisfaction OR marital relationship OR relationship OR social OR social functioning OR attitudes OR parent-infant relationship OR meaning of mothering OR perceptions Healthcare outcomes: healthcare OR antennal care OR antenatal need* OR postnatal care OR Postnatal need* OR childbirth OR birth Psychological, social and healthcare outcomes connected by ‘OR’ 5 Research type (R) Qualitative OR Experience* OR Narrativ* OR Interpretative Phenomenological Analysis OR IPA OR lived experience* OR Thematic Analysis OR Grounded Theory OR Content analysis The above were connected in the following way: S AND PI AND D AND E AND R * Truncation used to broaden search terms to include various word endings and spellings. References were exported to Endnote Reference Managing software (Clarivate Analytics UK Ltd [version 20], 2020) removing duplicates. Titles and abstracts were screened against inclusion criteria by the first author. Full text versions of retained articles were assessed for eligibility. Database searches were supplemented by forward and backward searching the reference lists of included studies. To reduce bias, an independent researcher, not attached to the research team, checked 15% of titles, abstracts and full-text papers for inclusion; 100% agreement was achieved. All authors were involved in the final decision of papers included in this review. Inclusion criteria for studies Studies were included if they 1) were an empirical study that used qualitative methods to explore and analyse gestating individuals and/or their partners’ experiences of pregnancy and parenting following successful MAC (i.e., studies were included even if only one parent reported their experiences), 2) were published in a peer-reviewed journal, 3) focused on MAC treatments, such as IVF, ICSI, Gamete Intrafallopian Transfer and the use of donor gametes. Those that specifically focused on Intrauterine Insemination (IUI) or Ovulation Induction (OI) were excluded due to their less invasive nature. However, mixed samples of MAC and IUI or OI were retained. Studies meeting the inclusion criteria published in any language were included and translated where possible. Grey literature was excluded. Studies were also excluded when they deviated from the experience of MAC itself and focused on specific topics, such as fertility, same-sex parenting, use of donor gametes or surrogacy and when they did not focus on the parents’ perspective or lived experiences, for example, only reporting professional views. Methodological quality and risk of bias assessment All studies were assessed for methodological quality using the Critical Appraisal Skills Programme (CASP) 17 qualitative checklist. The CASP is widely employed quality assessment tool in qualitative health-related synthesis 18 and includes questions relating to study validity, design and results. A numerical value was prescribed to checklist items (No = 0, Can’t Tell = 0.5, Yes = 1) to generate a useful indicator for comparison, an approach adopted in a previous meta-synthesis 19 . The total CASP score for each paper was then categorised as either ‘high’ (>8-10), ‘moderate’ (6-8) or ‘low’ ( 5) quality. An independent reviewer rated 50% of the included papers to assess reliability, with any disagreements being resolved through discussion. Data extraction and synthesis approach Relevant data were extracted from the studies and tabulated chronologically according to antenatal experience, postnatal experience or studies covering both. A thematic synthesis was adopted allowing for new interpretation of multiple findings and the development of analytical themes, furthering understanding 20,21 . A critical realist perspective position was adopted as the epistemological stance 22 due to its focus on understanding, rather than describing phenomena. Central to the critical realist position is integrating ontology, (what is real independent of our perceptions?) with constructivist epistemology 23 . All text under the original papers’ ‘Results’ or ‘Findings’ headings were extracted into NVivo software (QSR International Pty Ltd., 2020). The first author undertook the stages of thematic synthesis 16 . This included line-by-line coding, the development of descriptive themes and analytical themes. Firstly, each line of the primary study’s findings was coded according to meaning and content. Following this, studies were coded into pre-existing codes and new codes created when required. The first author looked for similarities and differences between the codes and they were grouped into related areas to develop descriptive themes. Codes were identified within and across studies and collated based on coherence. Analytical themes were then developed inductively by synthesising the findings across studies, interpreting their meaning. An experienced qualitative post-doctoral researcher scrutinised the data to ensure codes and themes were appropriately derived from the data and were acceptable. All themes and subthemes were discussed, refined and agreed by all authors. The Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) checklist 24 (see Appendix 1) was also completed. Reflexivity statement Reflexivity is a central component of qualitative research as the researchers’ assumptions, beliefs and prior experiences, both personal and professional, influence the research process. Acknowledgement of the researchers’ reflexive position enhances rigour, credibility and extends understanding of the findings 25 . The academic research team comprised of four white British and/or European women who had a wealth of clinical, academic and lived experience. All research team members had a firm philosophy in patient-centred, preventative care and a shared interest in understanding the psychological factors impacting expectant and new parents. The first author was a practising Trainee Clinical Psychologist who had experience of working antenatally and postnatally with expectant and new parents experiencing relational difficulties. DS was an experienced Health Psychologist and AW a Clinical Psychologist and researcher, with particular interests in parenting and maternal mental health during the perinatal period. LH was an expert, working clinically and in a research capacity, in the field of Obstetrics, bringing a medical perspective. All members of the research team were mothers with varying experiences of conception, including IVF, pregnancy, and loss. The first author kept a reflective log throughout the research process. Interpretations were shared between the first author and DS, challenging each other’s pre-conceptions, allowing new meaning to be distilled. Regular discussions amongst the research team were had regarding the interpretation of data, reflecting on our positioning, challenging our own biases and beliefs. Results Study characteristics From an initial 2,513 search results, 20 qualitative studies, based on 19 samples were included in the review (see Figure 1). The studies represented the experiences of 300 individuals. Most studies were conducted in Asia (n=7) and Europe (n=7) followed by, South America (n=5), and Australia (n=1). Six studies were translated to English using an online service (www.online doctranslator.com) and checked for accuracy by native speakers. The average sample size was 15, ranging from 3 to 51 participants. The studies captured the views of mothers/expectant mothers (n=13), fathers/expectant fathers (n=2) and couples (n=5), antenatally (n=12), postnatally (n=4) or their experiences of both (n=4). Many studies explored participants’ views and experiences of pregnancy and parenting more generally (n=16). Some studies focussed on breastfeeding (n=1), the couple’s relationship (n=1), physical activity (n=1) and the midwifery care needs of participants (n=1). Table 2 summarises the study characteristics. Table 2: Overview of all 20 included studies Authors and location Aims Data collection Participant demographics MAC detail Data analysis Main themes Studies exploring the antenatal period and birth 1 Dornelles, MacCallum, Lopes, Piccinini and Passos (2016) 35 Brazil To understand the perceptions of pregnancy achieved after ART Whether the above experience is affected by previous failed treatment cycles. Semi-structured interviews (Length approximately 90 minutes) 19 expectant first-time mothers in the third trimester of pregnancy Demographics Mean age 35 years (range 25-44) Ethnicity White = 16 (89%|) Marital status Married = 12 (63%) Cohabiting = 7 (37%) Education University degree = 12 (63%) High school = 7 (37%) Pregnancy Singleton = 15 (79%) Twins = 1(5%) Triplets = 3 (16%) MAC indication Female = 15 (79%) Male = 2 (10.5%) Combined = 1 (5.3%) Unexplained = 1 (5.3%) MAC type IVF = 15 (79%) OI = 0 (0%) IUI =3 (16%) Not specified a =1 (5%) MAC treatment history First attempt =11 (57%) Two or more attempts = 8 (43%) Thematic analysis (Laville & Dionne 1999) 65 Three main themes: 1) Tolerance of the demands of treatment/pregnancy 2) Consideration of the mechanics of treatment and pregnancy 3) Emotionally painful aspects of treatment/pregnancy 2 Sonego., Dornelles, Lopes, Piccinini and Passos (2017) 16 Brazil To investigate the experience of pregnancy after ART from the father’s perspective. Semi-structured interview using the Pregnancy and Expectations of the Future Father (NUDIF, 1998b (Length approximately 90 minutes) 13 men whose partners were in the 3 rd trimester of pregnancy Demographics Mean age Not reported (range = 32-46 years) Ethnicity Not reported Marital status Married or cohabiting = 13 (100%) Education Elementary school = 2 (15%) High school = 4 (31%) Incomplete higher education = 1 (8%) Completed higher education = 6 (46%) Pregnancy Single = 10 (77%) Multiple = 3 (23%) MAC indication Female = 9 (69%) Male = 3 (23%) Combined = 1 (8%) Unexplained = 0 (0%) MAC type IVF = 9 (70%) OI = 0 (0%) IUI = 2 (15%) Not specified a = 2 (15%) MAC treatment history First attempt = 7 (54%) Two or more attempts b = 6 (46%) Content analysis (Laville & Dionne, 1999) 65 Two main themes: 1) Subjective experience of the father during pregnancy 2) Effects of treatment on the experience of pregnancy 3 Walker, Mills and Gilchrist (2017) 10 UK To explore the qualitative experiences and decision-making processes regarding physical activity in women who have undergone IVF Individual semi-structured interviews (Length not reported) 8 women who had successfully conceived via IVF/ICSCI in the last two years Demographics Mean age 33 years old (range = 24-39) Ethnicity White British = 8 (100%) Marital status Not reported Education Not reported Pregnancy Not reported MAC indication Not reported MAC type IVF = 8 (100%) OI = 0 (0%) IUI = 0 (0%) Not specified = 0 (0%) MAC treatment history Not reported Interpretative Phenomenological Analysis (IPA; Smith, Flowers & Larkin, 2009) 66 Three main themes 1) Navigating away from childlessness and towards motherhood 2) Negotiating a safe passage 3) Balancing the challenges of pregnancy with the needs of the self 4 Warmelink, Adema, Pranger and Paul de Cock (2016) 40 Netherlands To investigate the midwifery care needs during pregnancy of couples or women who have conceived as a result of fertility treatment. Semi-structured, in-depth interviews (Average length 55 minutes. Ranged from 28-91 minutes) 9 interviews with 11 participants (two couples: Female = 9; Male = 2) Demographics Mean age Female mean age = 34.1 years (range = 32-38 years) Male mean age = 33.5 years (range = 32 -35 years) Ethnicity Dutch = 100% Marital status Not reported Educatio n Not reported Pregnancy Not reported MAC indication Female = 2 (22%) Male = 4 (44%) Combined = 1 (11%) Unexplained = 2 (22%) MAC type IVF = 10 (91%) OI = 0 (0%) IUI = 1 (9%) MAC treatment history Not reported Content analysis (Boeije, 2008) 67 Four main themes: 1) Normal but not normal: Paradoxical feelings 2) Understanding the impact of previous history 3) Psychosocial support 4) Care needs in general 5 French, Sharp and Turner (2015) 12 UK To explore the antenatal experiences of males and females who have successfully conceived via fertility treatment Individual interviews (Length approximately 1-3 hours) 20 participants 12 females; 8 males interviewed at 28 weeks’ gestation of first pregnancy Demographics Mean age Not reported (Age range = 35-39 years) Ethnicity Not reported Marital status Not reported Education Not reported Pregnancy Not reported MAC indication Female = 7 (35%) Male = 6 (30%) Combined = 2 (10%) Unexplained = 5 (25%) MAC type IVF = 17 (85%) OI = 2 (10%) IUI = 1 (5%) MAC treatment history Not reported Thematic analysis- constant comparison (Patton, 1990) 69 Four main themes: 1) Fear of pregnancy loss 2) Difficulty adjusting to pregnancy and planning for parenthood 3) Gaps in care 4) Self-silencing 6 Ranjbar, Akhondi, Borimnejad, Ghaffari and Behboodi-Moghadam (2015) 9 Iran To explore how women make sense of assisted pregnancy in Iranian culture and context Semi-structured, interviews (Length approximately 30-60 minutes) 12 women who experiences assisted pregnancy with their first child Demographics Mean age 29.51 (Age range = 24-36) Ethnicity Iranian Kurd = 2 (17%) Fars = 6 (50%) Turk = 3 (25%) Lor = 1 (8%) Marital status 100% married Education MSc/MA = 2 (16.7%) BS = 3 (25%) High School = 6 (50%) 9 th grade = 1 (8%) Pregnancy Single = 12 MAC indication Female =12 (100%) Male = 0 (0%) Combined = 0 (0%) Unexplained = 0 (0%) MAC type IVF = 12 (100%) OI = 0 (0%) IUI = 0 (0%) Not specified = 0 (0%) MAC treatment history Not reported Interpretative Phenomenological approach (Van Manen, 1990) 70 Three main themes: 1) Finding peace in life 2) Paradoxical feelings 3) Struggling to realise a dream 7 Dornelles, MacCallum, Lopes, Piccinini and Passos (2014) 33 Brazil To explore women’s fears during pregnancy following conception via assisted reproductive technology (ART) Semi-structured interviews (Length approximately 90 minutes) 19 first time mothers in their third trimester of pregnancy Demographics Mean age 35 years (range 25-44) Ethnicity White = 17 (89%) Other ethnicity = 2 (11%) Marital status Married = 12 (63%) Cohabiting = 7 (37%) Education University degree = 12 (63%) High School graduates = 7 (37%) Pregnancy Single pregnancy = 15 (80%) Twins = 1 (5%) Triplets = 3 (15%) MAC indication Female = 15 (79%) Male = 2 (11%) Combined = 1 (5%) Unexplained = 1 (5%) MAC type IVF = 15 (79%) OI = 0 (0%) IUI = 3 (16%) Not specified a = 1(5%) MAC treatment history First attempt = 10 (53%) Two or more attempts = 9 (47%) Content Analysis (Laville & Dionne, 1999) 65 Four main themes: 1) The baby’s survival 2) The health of the baby 3) The efficacy of the other 4) Childbirth 8 Lin, Tsai and Lai (2013) 34 Taiwan To describe the experiences of pregnancy in Taiwanese women who had undergone at least three cycles of ART over a period exceeding three years In-depth interviews (Length approximately 90-120 minutes) 15 females interviewed within one year of delivering a baby Demographics Mean age 39 years (range 31-44) Ethnicity Not reported Marital status Married = 15 (100%) Education MSc = 5 (33%) Bachelor’s degree = 8 (53%) Junior college degree = 1 (7%) High School Diploma = 1 (7%) Pregnancy Not reported MAC indication Female factor = 15 (100%) Male factor = 0 (0%) Combined = 0 (0%) Unexplained = 0 (0%) MAC type IVF = 15 (100%) OI = 0 (0%) IUI = 0 (0%) Not specified = 0 (0%) MAC treatment history First attempt = 0 (0%) Two or more attempts = 15 (100%) Phenomenological qualitative method Procedures adopted by Creswell (2009) 23 . Five main themes: 1) Emphasis on the safety and health of the foetus 2) Psychosocial reactions to physical and physiological conditions 3) Transition of identity 4) Insights after going through pregnancy and labour 5) Impact of society on pregnancy 9 Smorti and Smorti (2013) 29 Italy To explore the psychological processes that develop in women and men during their first pregnancy obtained with assisted reproduction treatment. Semi-structured autobiographical interview (Length approximately (50-90 minutes) 15 Italian couples pregnant with their first child (29 th -34 weeks pregnant) Demographics Mean age Female = 36 years Male = 38 years Ethnicity White = 14 (93%) Other ethnicity = 1 (7%) Marital status Married or cohabiting = 15 (100%) Education Women degree or high school = 13 (87%) Men completed secondary school = 13 (86%) P regnancy Single = 12 (80%) Twins = 2 (13%) Multiple pregnancy = 1 (7%) MAC indication Female = 6 (40%) Male = 5 (36%) Combined = 1 (4%) Unexplained = 3 (20%) MAC type IVF = 7 (48%) OI = 0 (0%) IUI = 8 (52%) Not specified = 0 (0%) MAC treatment history First attempt = 6 (40%) Two or more attempts = 9 (60%) Identification of themes, patterns on global and qualitative level. Participants narrated their pregnancy experience as a process with four main phases: 1 st phase: ‘Doubt’ phase 2 nd phase: Anxious and overwhelming need to seek help and support re: fertility 3 rd phase: struggle and the victory. 4 th phase: The monitoring phase 10 Dornelles and Lopes (2011) 30 Brazil To understand the process of becoming a mother in the context of ART. Interview on Pregnancy and Expectations of the Pregnant women (NUDIF, 1998b) (Length not reported) 3 participants in their third trimester of pregnancy with their first child. Mean age 35 years (range = 25-37) Ethnicity Not reported Marital status Not reported Education: Higher education: 2 (67%) Middle education: 1 (33%) Pregnancy Not reported MAC indication Female = 1 (33%) Male = 1 (33%) Combined = 0 (0%) Unexplained = 1 (33%) MAC type IVF = 1 (33%) OI = 0 (0%) IUI = 1 (33%) Not specified a = 1 (33%) MAC treatment history First attempt = 1 (33%) Two or more attempts = 2 (66%) Content Analysis (Laville & Dionne, 1999) 65 6 main themes 1) Life growth theme 2) Theme relating to primary 3) Support matrix – 4) Identity reorganisation – 5) Stages of conception: pregnancy 6) Imaginary baby 11 Silva and Lopes (2011) 37 Brazil To investigate the marital relationship during treatment and pregnancy in couples who became pregnant with the help of ART Semi —structured interviews (Length approximately 120 minutes) 6 participants (three couples) Mean age and range Not reported Ethnicity Not reported Marital status In a relationship = 6 (100%) Education Higher education = 4 (67%) Elementary school = 2 (33%) Pregnancy status Not reported MAC indication Female = 2 (33%) Male = 1 (33%) Combined = 0 (0%) Unexplained = 0 (0%) MAC type IVF = 2 (66%) OI = 0 (0%) IUI = 0 (0%) Not specified a = 1 (33%) MAC treatment history First attempts = 1 (33%) Two or more attempts = 2 (66%) Content Analysis (Laville & Dione, 1999) 65 Six main themes: 1) Cohesion during treatment 2) Cohesion during pregnancy 3) Sexuality during treatment 4) Sexuality during pregnancy 5) Communication during treatment 6) Communication during pregnancy 12 Hayashi and Sayama (2009) 11 Japan To qualitatively highlight the emotional processes experienced by women who achieved pregnancy via assisted reproductive technology Semi-structured interviews (Average length = 64.5 minutes; range = 46-87 minutes) 8 primiparas who achieved pregnancy via ART one to six months after delivery. Demographics Mean age 34 years (age range = 28-42) Ethnicity Not reported Marital status Not reported Education status Not reported Pregnancy status Single = 6 (75%) Twins = 2 (25%) MAC indication Not reported MAC type IVF = 7 (88%) OI = 0 (0%) IUI = 0 (0%) Other = 1 (12%) MAC treatment history Not reported Phenomenological study method (Colazzi, 1978) 70 Nine main themes: 1) Feelings of mission and pressure by becoming pregnant 2) Attention to the avoided jealousy 3) Wisdom in overcoming anxiety 4) Maternal self-consciousness 5) Release from feelings of loneliness 6) Recovery of self-confidence 7) Positive acceptance of infertility and the treatment experience 8) Confirming one’s own growth 9) Feeling authentic joy from pregnancy Studies exploring birth and/or postpartum experiences 13 Díaz Sáez, Fernandez-Medina, Granero-Molina, Fernandez-Sola, Hernandez-Padilla and Lopez-Rodrugues (2021) 28 Spain To describe and understand the breastfeeding experiences of first-time mothers who conceived using ART Focus group (n = 8) lasting 86 minutes and Individual semi-structured interviews (n = 19) (Average length = 37 minutes.) 27 women first time mothers Demographics Mean age 38 years (age range = not reported) Ethnicity Not reported Marital status Married = 21 (78%) Cohabiting = 6 (22%) Education Higher Education = 15 (56%) Medium = 2 (7%) Basic = 10 (37%) Pregnancy Single = 27 (100%) MAC indication Not reported MAC type IVF = 16 (59%) OI = 0 (0%) IUI = 11 (41%) Not specified = 0 (0%) MAC treatment history Not reported Hermeneutic phenomenology (Gadamer, 2005) 71 Two main themes: 1) The transition from infertility to motherhood 2) The reality of becoming a breastfeeding mother after ART 14 Sadeghi, Mohammadi, Mohammadpourand and Abbasi (2019) 39 Iran To investigate the challenges mothers face after assisted-reproduction techniques Part of a larger phenomenological study that aimed to discover the experience of motherhood after ART Sem- structured interviews, (Length not report) 13 mothers who conceived via ART Demographics Mean age 32 years Ethnicity Not reported Marital status Not Reported Education Diploma = 7 (54%) Bachelor = 6 (46%) Pregnancy Not reported MAC indication Female = 8 (62%) Male = 5 (38%) Combined = 0 (0%) Unexplained = 0 (0%) MAC type IVF = 9 (69%) OI = 0 (0%) IUI = 3 (31%) Not specified = 0 (0%) MAC treatment history Not reported Hermeneutic Phenomenological method incorporating thematic analysis (Van Manen, 1990) 69 One main theme: 1) ‘Over-challenged mother’ 15 Mohammadi, Shamshiri, Mohammadpour, Vehilainen-Julkunen, Abbasi and Sadeghi (2015) 36 Iran To explore and describe the experience and meaning of mothering after ART among Iranian women Semi structured interviews (Length approximately 45-70 minutes) 9 first time mothers Demographics Mean age 32 years (age range = 28-45) Ethnicity Not report Marital status Not reported Education Diploma = 6 (67%) Bachelor = 3 (33%) Pregnancy Not reported MAC indication Female = 6 (67%) Male = 3 (33%) Combined = 0 (0%) Unexplained = 0 (0%) MAC type IVF = 6 (67%) OI = 0 (0%) IUI = 3 (33%) Not specified = 0 (0%) MAC treatment history Not reported Heideggerian hermeneutic Phenomenological approach (cited in Van Manen, 1990) 69 One main theme: 1) ‘Super-mothering’ 16 Bracks- Zalloua, McMahon and Gibson (2011) 38 Australia To provide an in-depth understanding of early parenthood for IVF-conceiving fathers Semi-structured interviews (Length approximately one hour) 8 men whose partners had conceived via IVF Demographics Mean age 40 years old (range 29-53 years) Marital status Married = 7 (88%) Cohabiting = 1 (12%) Ethnicity Western = 8 (100%) Pregnancy Not reported MAC indication Female = 4 (50%) Male = 4 (50%) Combined = 0 (0%) Unexplained = 0 (0%) MAC type IVF = 8 (100%) OI = 0 (0%) IUI = 0 (0%) Not specified = 0 (0%) MAC treatment history Not reported Modified Analytic Induction (Bogdan & Biklem, 1998) 72 Three main themes: 1) The concerned partner 2) Inattention from partner 3) Interaction with child Studies exploring the antenatal and postnatal period 17 Boz, Teskereci and Akgun (2021) 32 Turkey The experience of becoming a mother following successful IVF: a grounded theory Semi-structured interviews (length not reported) 18 mothers who had become pregnant and had a child following successful IVF Demographics Mean age 32 years (age range = 27-39) Ethnicity Not reported Marital status Not reported Education Higher education = 6 (33%) High school = 2 (11%) Secondary school = 8 (44%) Vocational school = 2 (11%) Pregnancy Not reported MAC indication Female = 2 (11%) Male = 6 (33%) Combined = 1 (6%) Unexplained = 9 (50%) MAC type IVF = 18 (100%) OI = 0 (0%) IUI = 0 (0%) Not specified = 0 (0%) MAC treatment history First attempt = 16 (89%) Two or more attempts = 2 (11%) Grounded Theory (Charmaz, 2014) 73 Four themes: 1) Non-spontaneous path to motherhood a) treatment 2) Leaving the infertility world 3) Pregnancy under the shadow of fear 4) Getting stuck between fertile and infertile worlds 18 Allan, Mounce, Cullem Van den Akket and Hudson (2019) 27 UK To explore non-donor IVF couples’ transition to early parenthood Unstructured interviews with couples (length approximately 40-60 minutes) 16 heterosexual couples with one live singleton infant Demographics Mean age Not reported (Female age range = 25-39) (Male age range = 29-41) Ethnicity Not reported Marital status Not reported Education Not reported Pregnancy Single = 16 (100%) MAC indication Not reported MAC type IVF = 16 (100%) OI = 0 (0%) IUI = 0 (0%) Not specified = 0 (0%) MAC treatment history First attempt = 9 (56%) Two or more attempts = 6 (38%) Unknown = 1 (6%) Thematically (Frost, 2010) 74 Three themes: 1) Preparing for parenthood 2) Becoming a parent 3) Considering a sibling 19 Crespo and Bestard (2016) 26 Spain To explore the psychosocial needs of women and their partners following assisted reproductive treatment in a Spanish Context Repeated rounds of semi-structured interviews (Length approximately 30-90 minutes) 51 participants (30 pregnant women; 21 partners) Demographics Mean age 37 years (age range = not reported) Ethnicity Spanish = 51 (100%) Marital status Married = 25 (83%) Single = 4 (13%) Divorced = 1 (3%) Education Higher education = 17 (57%) Secondary = 9 (30%) Primary = 4 (13%) Pregnancy Not reported MAC indication Female – not reported Male – not reported Combined – not reported Unexplained – not reported Same-sex couple = 1 (3%) One lone parent = 1 (3%) MAC type IVF = 26 (87%) OI = 0 (0%) IUI = 4 (13%) MAC treatment history Not reported Does not state – text was coded into either predetermined or emergent topics Two major themes: 1) Complexity of reasons for anxiety 2) Narrowing experience 20 Katsumara, Kamiya and Emisu (2014) 31 Japan To clarify the experiences from pregnancy with a first child to puerperiuem and childcare, of women who became pregnant through fertility treatment. Semi-structured interviews (length approximately 29-60 minutes) 9 women who received fertility treatment for a second pregnancy after giving birth to a first child through fertility treatment Mean age 37 years old (range = 33-43 years old) Ethnicity Not reported Marital status Not reported Education Not reported Pregnancy Not reported MAC indication Female = 4 (44%) Male = 1 (12%) Combined = 0 (0%) Unexplained = 4 (44%) MAC type IVF = 6 (67%) OI = 0 (0%) IUI = 2 (23%) MAC treatment history Not reported Content Analysis (Greg et al., 2007) 75 17 main themes: 1) Growing desire for a second child; contrary to expectations 2) Lack of actual sense of pregnancy and delivery 3) Joy and pride in pregnancy 4) Anxiety and reassurance in selecting a birthing facility 5) Feeling of relief at having to come this far on a long journey 6) Acceptance that one can not have a natural delivery 7) Fluctuation between anxiety and abnormalities or disorders in the fetus and feeling that it will be all right 8) Thankfulness and stress with respect to family 9) Uncertainty about continuation of pregnancy 10) Longing for the birth of a healthy child 11) Delivery with little sense of fulfilment 12) Joy at becoming a mother and motivation for child rearing 13) Joy felt from existence of baby 14) Easing of worries regarding baby 15) Anxiety about raising one’s first child despite joyful birth after much difficulty 16) Weakness of one’s feelings and emotion towards birth 17) Connection between unsettling events and medical treatment. Abbreviations: IVF, In-Vitro Fertilisation; OI, Ovulation Induction; IUI, Intrauterine Insemination. a Gamete donation – unknown whether this was sperm or egg donation The most reported demographic information was age (n=19), followed by education (n=12), marital status (n =8) and ethnicity (n=8). Participants ranged from 24 to 53 years in age and were commonly educated to degree level (see Table 2). Various MAC methods were recorded across studies, including IVF (n = 18), ICSI (n=7) and the use of donor gametes (n=6). Eleven studies had mixed samples of MAC and other less invasive forms of treatment, such as IUI or OI. Most studies (n=17) recruited individuals with a history of infertility; only one study recruited a mixed sample including a same-sex couple and a lone parent 26 . Three studies did not report the reason for MAC 10, 27, 28 . All studies collected data via interview, ranging in length from 29 to 180 minutes. The qualitative methodology most frequently employed was Interpretative Phenomenology (n=7) followed by, Content Analysis (n=6) Thematic Analysis (n=3), Grounded Theory (n=1) and Modified Analytic Induction (n=1). Two studies did not specify their method 26, 29 . Quality appraisal and risk of bias of studies Methodological quality varied across studies, as can be seen in Table 3. Agreement between raters was (94%, k = 0.765, p<.001, rated as ‘substantial agreement’). Most studies were rated as ‘moderate’ quality (n=13), followed by high (n=5). Two studies 30,31 were rated low in quality. No studies sufficiently referenced reflexivity, a fundamental process to qualitative research; this was a general weakness of all studies. Table 3: Overview of the methodological quality appraisal of the 20 included studies Study Aims Methodology Design Recruitment Data collection Reflexivity Ethical issues Data analysis Statement of findings Valuable Score and overall rating (0-10) 1 Dornelles et al. (2016) 35 Yes (1) Yes (1) No (0) C T (0.5) Yes (1) No (0) Yes (1) C T (0.5) Yes (1) Yes (1) Moderate (7) 2 Sonego et al. (2017) 14 Yes (1) Yes (1) No (0) C T (0.5) Yes (1) No (0) No (0) C T (0.5) Yes (1) Yes (1) Moderate (6) 3 Walker et al. (2017) 10 Yes (1) Yes (1) Yes (1) No (0) C T (0.5) C T (0.5) C T (0.5) C T (0.5) Yes (1) Yes (1) Moderate (7) 4 Warmelink et al. (2016) 40 Yes (1) Yes (1) C T (0.5) C T (0.5) C T (0.5) N (0) C T (0.5) Yes (1) Yes (1) Yes (1) Moderate (7) 5 French et al. (2015) 12 Yes (1) Yes (1) C T (0.5) Yes (1) Yes (1) No (0) C T (0.5) Yes (1) Yes (1) Yes (1) High (8) 6 Ranjbar et al. (2015) 9 Yes (1) Yes (1) C T (0.5) No (0) C T (0.5) No (0) Yes (1) Yes (1) Yes (1) Yes (1) Moderate (7) 7 Dornelles et al. (2014) 33 Yes (1) Yes (1) No (0) C T (0.5) C T (0.5) No (0) Yes (1) No (0) Yes (1) Yes (1) Moderate (6) 8 Lin et al. (2013) 34 Yes (1) Yes (1) Yes (1) Yes (1) Yes (1) No (0) C T (0.5) Yes (1) Yes (1) Yes (1) High (8.5) 9 Smorti and Smorti (2013) 29 Yes (1) Yes (1) Yes (1) Yes (1) Yes (1) No (0) C T (0.5) No (0) Yes (1) Yes (1) Moderate (7.5) 10 Dornelles and Lopes (2011) 30 Yes (1) Yes (1) C T (0.5) C T (0.5) No (0) No (0) C T (0.5) No (0) Yes (1) No (0) Low (4.5) 11 Silva and Lopes (2011) 37 Yes (1) Yes (1) No (0) Yes (1) C T (0.5) No (0) Yes (1) No (0) Yes (1) C T (0.5) Moderate (6) 12 Hayashi and Sayama (2009) 11 Yes (1) Yes (1) Yes (1) C T (0.5) Yes (1) No (0) Yes (1) Yes (1) Yes (1) No (0) Moderate (7.5) 13 Díaz Sáez et al. (2021) 28 Yes (1) Yes (1) Yes (1) C T (0.5) C T (0.5) No (0) Yes (1) C T (0.5) Yes (1) Yes (1) Moderate (7) 14 Sadeghi et al. (2019) 39 Yes (1) Yes (1) Yes (1) C T (0.5) Yes (1) C T (0.5) Yes (1) C T (0.5) Yes (1) Yes (1) Moderate (7.5) 15 Mohammadi et al. (2015) 36 Yes (1) Yes (1) Yes (1) Yes (1) Yes (1) No (0) Yes (1) C T (0.5) Yes (1) Yes (1) High (8.5) 16 Bracks-Zalloua et al. (2011) 38 Yes (1) Yes (1) Yes (1) Yes (1) Yes (1) No (0) No (0) Yes (1) Yes (1) Yes (1) High (8) 17 Boz et al. (2021) 32 Yes (1) Yes (1) Yes (1) Yes (1) Yes (1) No (0) Yes (1) Yes (1) Yes (1) Yes (1) High (9) 18 Allan et al. (2019) 27 Yes (1) Yes (1) C T (0.5) C T (0.5) Yes (1) No (0) Yes (1) No (0) Yes (1) Yes (1) Moderate (7) 19 Crespo and Bestard (2016) 26 Yes (1) Yes (1) Yes (1) C T (0.5) Yes (1) No (0) C T (0.5) C T (0.5) C T (0.5) Yes (1) Moderate (7) e 20 Katsumara et al. (2014) 31 Yes (1) Yes (1) C T (0.5) No (0) C T (0.5) No (0) Yes (1) No (0) No (0) C T (0.5) Low (4.5) % of included studies rated as ‘Yes’ 100% 100% 50% 35% 60% 0% 55% 35% 90% 80% Abbreviation: CT, Can’t Tell . Findings Three main themes and seven subthemes were identified (Figure 2) which will be illustrated through selected quotes. A matrix of themes (see Appendix 2) illustrates which themes were present for each study. Theme 1: The vulnerable parent: fear, doubt and uncertainty This theme, consisting of two subthemes, encompasses the uncertainty, doubt and fear individuals experienced as they entered pregnancy, lacking a sense of safety. Commonly, this lack of safety was expressed in hypervigilance, fears of pregnancy loss and fetal abnormalities, with parents living cautiously, seeking reassurance and acting to protect their child during pregnancy and parenting. Subtheme 1.1: Lacking a sense of safety Pregnancy was an emotionally overwhelming time for expectant parents. Ambivalence often accompanied successful conception with paradoxical feelings reported 9, 26, 31, 32 For some, it was described as “the end of a nightmare” 29 (p.171) , feeling victorious that their “fight” 29 (p.171) with fertility or MAC was over. Others attempted to limit their excitement, as a form of self-protection: “I think to a certain extent until he almost turned up, there was part of me that was just like, I guess having gone through the whole IVF thing, I was just like, I just don’t want to get too excited…” 27 (p.25) . Doubt and disbelief regarding the pregnancy were expressed 9, 12, 32-34, linked to previous failed attempts to conceive 31, 34, 35 . Intense states of worry quickly followed with fears regarding the viability of the pregnancy and miscarriage prominent 11, 12, 27, 29-35 , particularly during the first trimester. The MAC journey influenced reactions to pregnancy: “ It’s taken so long to get here, that it’s not the same, or maybe it is, we don’t know; but a woman who gets pregnant naturally or has no trouble getting pregnant may not think about things as much as someone who’s spent two years going through this process ” 26 (p.95) . These reactions led to significant value being placed on the pregnancy 14,35 with difficulties in imagining a future life with their baby: “ I always feared that something would happen to my child. As if taking it in my arms was impossible… ” 32 (p. 4177) . For some, these fears diminished at significant milestones 12,29 , with a growing sense of stability as the pregnancy progressed 34 . However, for others, these worries persisted throughout, switching to fears of stillbirth 30,31,33 . In papers that discussed the non-gestating partners’ perspectives (in this case, all male partners’ perspectives) these fears were often less apparent 12,14,29 , reassured by their partners’ changing bodies. Individuals lacked trust in their own bodies 11,12 and feared they could not sustain the pregnancy : “…t o be honest I just stopped trusting my body, it never behaves at it should do, if you expect it to do something, it will do something else” 12 (p.573) . These fears often became an obstacle to live the pregnancy fully, impacted bonding: “ Now I am in doubt whether I should bond with her. What if something happens to that or a problem occurs” 9 (p.5) . Participants were reluctant to disclose or were eager to minimise the physical and psychological burdens of pregnancy and the impact of MAC treatment ,35 , due to their long desire to be parents. For some, pregnancy was viewed as a “reward” that “compensated” 35 (p.125) for the challenges they had encountered. However, studies published in the UK reported a reduced entitlement to complain about the challenges of pregnancy and parenting 12,27 , reflecting potential cultural differences. The health of the baby was a dominant theme across studies. Concerns regarding fetal abnormality 11,30,31,33,34 , prematurity 11,31,34 and disability 11 were found. These feelings were heightened before or during prenatal visits 35 and often persisted throughout pregnancy 33 . For some, the fear of abnormalities and disabilities disappeared upon greeting their baby 31 , whereas for other parents this persisted into the parenting journey, considering their child more vulnerable to illness and injury 36 . Subtheme 1.2: Acting to protect The uncertainty, anxiety and fear associated with pregnancy often led to hypervigilance, and monitoring of bodily symptoms 9, 11, 14, 27, 34, 36, ,with any indication of difficulty destabilising individuals, causing emotional turmoil: “I always checked my underwear in bathroom to see if there is any problem. Two weeks ago it seemed that I had some brownish spots. It was the time when I just sat and started crying loudly” 9 (p.5) . On noticing any physiological changes, individuals swiftly sought the help of health professionals. For expectant fathers, this anxiety was expressed through constant checking and monitoring of their partner: “Every time (mother) left the room I was like ‘you alright, alright?’ Every time, I was like ‘is everything alright” 27 (p.439) . A need for reassurance was evident leading individuals to repeatedly perform pregnancy tests 12,26,27,32 and seek medical help 11,34 : “After I learned that I was pregnant, I kept repeating the urine pregnancy tests every day. I was so afraid that the baby was not inside ” 32 (p.4177) . Changes in body shape and fetal movement helped individuals fully realise and believe in their pregnancy 32 , increasing their sense of responsibility and feelings of protection 11 . MAC added to the fragility of pregnancy: “Because he was IVF you kind of think, because he didn’t happen naturally, you’re extra careful and extra cautious because it was like, it is your one shot” 27 (p.439) . Both parents reported a growing sense of responsibility 9,14,29 , with the developing baby prioritised: “ I took a LOA for one year and rested in bed for a long time. There was only one focus in my life at the time, the babies inside me. I knew that only I was able to protect the two babies in my belly. I had to guard them with my life ” 34 (p.4) . This responsibility led to acts of protection and modification of lifestyle such as delaying or reducing physical activity 9,10,30,32,34 , working patterns 11,34 , sexual intercourse 9,37 and changes to diet 10,34 . This sense of caution resulted in delayed preparations 11,12 , including arranging the nursery or buying items : “You know, people keep saying, ‘Have you decorated the nursery?’ and I can’t think of anything worse than coming home to a decorated nursery, you know, if, if things go wrong you know ” 12 (p.173) . Expectant fathers reported feeling protective of their pregnant partner, “ taking care ” of them 14 (p.4) , by attending appointments, providing emotional and financial support 14 . These feelings of protection persisted into the parental journey 32,36 , with parents attempting to safeguard their infant from harm. Theme 2: The stark realisation of the parental dream The journey to parenthood often starkly contrasted to individuals’ hopes and expectations. For some, the process of becoming a parent was embraced, whereas others struggled to realise their dream. This theme, with its three subthemes, encapsulates individuals’ transition of identity, approaches to parenting and their onward journey, considering future family formation. Subtheme 2.1: Navigating old and new identities The transition in identity began at the point of conception for some 11 . However, for others this was a complicated process with a “ fragile, obscure and unstable ” identity 34 (p.5) , particularly during the first trimester. Achieving pregnancy did not erase individuals’ conception journey, impacting their ability to embrace their newly emerging identity 10,30,32,34 , causing disturbances in the self: "it may come to something positive [changes brought about by maternity], maybe not, ... I lost my personality, my identity... . Who am I?" 33 (p.494) . Couples’ views on MAC impacted their ability to accept their new identity expressing concerns about their ability to care for their baby 33 . Some minimised 11,35,38 and “ rejected” 27 (p.441) their previous infertility and the impact of MAC, whereas others demonstrated acceptance 11,26 . The birth was a significant moment in the transition of identity. For some, there was a strong desire to birth naturally with feelings of disappointment and regret at requiring medical intervention 31 . Following the birth, feelings of “ shock ” 26 (p.70) were reported. For many, physically seeing or holding their infant was necessary to realise their parental identity and joy 11,14 : "I want to do my best to raise my baby by seeing and touching my baby and realizing that I have become a mother" 31 (p.225) . Feeling “ complete ” 34 (p.6) upon their baby’s arrival and viewing their parenting role as “ amazing ”, or “ incredible ” 27 (p.440) were reported: “ The joy of having a baby is much greater than winning a lottery . . . I think that is the greatest happiness in my life. This is something I could never have realised before I became a Mum ” 34 (p.6) . However, the lasting impact of MAC was evident for parents, fading into the background, yet etched in their minds: “ And I remember feeling that I wouldn’t ever forget how hard that actually was to go through the treatment and I don’t think I have to some extent, but I feel like it’s faded a bit into the background” 27 (p.442) . Pregnancy and motherhood were considered fundamental to being a woman: “becoming a mother really meant feeling like a woman” 32(p.4179) . Individuals reported feeling more valued because of their pregnancy, increasing self-confidence, reclaiming their sense of self 9,11,30 and restoring trust in their bodies’ capability 11,32 . Subtheme 2.2: The need to be a perfect parent, for their precious baby The pregnancy and baby were often viewed as “ precious ” 27 (p.442) ,32 (p.4179) , “ delicate ” 33 (p.118) , “ special ” 35 (p.126) or “ highly valued ” 38 (p.2) , impacting approaches to parenting. This presented with parents needing to provide “ perfect ” care 32 (p.4179), 36, (p.48) , centring their lives around the infant, with parental needs secondary 32,38,39 . This parental approach sometimes led to more permissive parenting styles, fulfilling the child’s every wish and a reluctance to provide consequences: “We would do everything she wanted ” 39 (p.1791) . Not only was the child viewed as highly “special”, but the mother also: “We are not better mothers, but more special. When you want something so much, you appreciate it and take care of it with more care. I worry a little more about him because he was so longed for” 28 (p.72) . Gratitude was expressed by parents 27 , acknowledging that their experience of MAC changed their “ perspectives ” 27 (p.441) and tempered the challenges parenthood brings, helping parents to maintain a sense of “ calm ” 27 (p.441) in stressful situations. The fears of loss apparent in pregnancy overspill into parenting 39 , leading to concern, “ over-protection ” 36 (p.48) and over-involved parenting 32,36,39 . This was characterised by constant monitoring 33,36,39 and supervision of their infants: “I’m very careful, I’m afraid that something bad happens for him, always keep an eye on him and keep him with me” 39 (p.1791) . Mohammadi et al. (2015) 36 reported an “ over-emotional investment ” characterised by enmeshment of mother and infant : “He saved my life. Every second I think about him, I’m totally obsessed with his future 36 (p.48) . Different approaches to parenthood were noted between male and female partners 38 , with fathers referenced as more “ laid back ”, “ playful ” and less protective 38 (p.7) . Contrary to this, Allan et al. (2019) 27 reported the unification of parents in their approach to parenthood, with close involvement and negotiation from both parents. Strong desires to breastfeed were reported 28,31, , with mothers wanting to offer their child the “best start” 28 (p.70) . Often individuals endured physical pain and self-sacrifice to continue with their quest to breastfeed : “The cracks hurt a lot, when I had been breastfeeding for a little, the pain went down a little bit, but I thought about stopping breastfeeding. I made the sacrifice and put up with the pain for him, and I don’t regret it” 28 (p.71) . Opposingly, prolonged breastfeeding was evident 28,38 , linked to feelings of protection and bonding. Subtheme 2.3: The onward journey Thoughts and feelings regarding future family formation and the decision to have another child were discussed 26,27,32,39 . Having another child was not viewed as a guarantee 39 , with many fearful of re-embarking on the MAC journey 32,39 , reminded of the emotional turmoil 27 , pain 27, 32 (p.4177) and anxiety 32 previously experienced. Attachment to frozen embryos were reported 27 and comments from others regarding a second child were hurtful reminders of their journey to conception 27 . Theme 3: Psychosocial needs and support This theme and its two subthemes captured individuals’ psychosocial care needs as they navigated complex health systems, relationships within their own support networks and the impact of sociocultural context. Subtheme 3.1: Unmet care needs Whilst the desire to receive routine antenatal care 39 and to be treated “like everyone else” 12 (p.574) were presented, the care needs of some individuals contradicted this 12,39 . Discharge from the fertility centre brought satisfaction, signalling the end of their MAC journey 40 . However, ambivalence regarding the transition was evident, with “ gaps in care ” reported 12 (p.574) . This was often an anxious time for individuals lacking in containment: “We didn’t really know who to turn to, we hadn’t seen our midwife yet and we needed to know everything was okay with the pregnancy, so we paid for a private dating scan ” 12 (p.574) . Participants’ care needs were not adequately addressed by routine services, with little understanding or attention from health professionals regarding their conception journey 12,40 . Increased care needs 40 were reported, requiring additional appointments and scans to contain their anxiety. There were barriers to discussing their concerns with health professionals in fear of being perceived as “ ungrateful ” 12 (p.105) , often requiring prompts from professionals to initiate discussions 40 . Nevertheless, certain qualities were valued in health professionals, such as knowledge regarding their conception journey, personalised care, clear and consistent communication, more frequent appointments, understanding and reassurance 10,12,40 . Subtheme 3.2: The journey from exclusion and marginalisation to acceptance and belonging Feelings of difference were experienced in pregnancy after MAC 9,11,12,27,32 . “ Resentment ” 27 (p.441) towards spontaneously conceiving couples was expressed, feeling others could not understand their journey to conception 12,32 , or the emotions that pregnancy brings 32 . The uncertainty associated with pregnancy often translated into reluctance to share their pregnancy news with others 9,11,26,29,34 : “ only tell immediate family and friends and then if it hasn’t worked, we can then be open and honest again, once we’ve kind of healed a bit” 10 (p.370) . Achieving pregnancy brought complex emotional reactions and a sense of betrayal to their previous childless identity 9,12 . Reports of guilt, empathy and sadness for those still trying to achieve pregnancy were commented upon 9,11 . Parents reported “ finding meaning in life ” 9 (p.4) once pregnancy was achieved, shifting from a position of isolation to connection, feeling supported by others such as health professionals, family and friends 9,32 , bringing hope and optimism 9 . Going through MAC and achieving pregnancy was reported to strengthen marital relationships 9,26,30,37 with the partner reported as the biggest source of support during pregnancy 34 . A reduction in conflict, improved communication and understanding were noted 37 . Furthermore, having a biological child led to greater feelings of acceptance and connection with the partner’s family: “ I was finally connected with my husband’s family after having the baby, and the baby represented a biological link. Otherwise, I would have always been an outsider” 37 (p.6) . As the pregnancy progressed, individuals relied on family and close friends 27 to provide practical and emotional support, both antenatally and postnatally 9,28,30,34 . Furthermore, making new connections with others who had conceived via MAC was a welcomed bonding experience 27 facilitated by internet forums 10 . Sociocultural norms regarding conception influenced individuals’ ability to integrate their former and current selves 27 . Having a child seemed to hold cultural significance, with the impact of society particularly evident in papers conducted in Asia. In some instances, individuals never disclosed their use of MAC in achieving pregnancy due to fears of shame and negativity from their community 9,39 . Individuals felt free from stigmatisation on achieving pregnancy 9 , feeling more accepted by others and society, increasing self-worth: “In every party or religious ceremony people came to me and said we bring this for you because of your pregnancy. The feeling and opinion of people toward me has changed now ” 9 (p.4) . The role of religion and spirituality was reflected upon 9,34,36, 39 , helping individuals manage and cope with the uncertainty and doubt that accompanied pregnancy: “Sometimes I feel that I can do nothing more myself. I read holy Quran and say prayers. I rely on the strength from God” 9 (p.6) . Parents prayed for a successful pregnancy 9,34 and, in some instances, attributed the birth to God 36 . Discussion This study achieved its aim of exploring the experiences of pregnancy and early parenting in individuals who conceived via MAC, identifying their psychological, social and health care needs. This is the first review to qualitatively synthesise the antenatal and parenting experiences of both parents who conceive via MAC. Overall, achieving pregnancy brought complex emotional reactions and lacked in a sense of safety, with amplified care needs identified. The health and survival of the baby preoccupied parents’ thoughts, leading to acts of protection and cautious living, impacting their transition to parenthood and their identity as a parent. This transition to parenthood can be a lengthy, non-linear process, influenced by health systems and the sociocultural context. This review confirmed that pregnancy following MAC was associated with pregnancy-specific anxiety, fears of pregnancy loss and concerns regarding the health of the baby 5,7,8 . This heightened state of threat impacts parents’ ability to imagine a life with their baby and, in some cases, impacts bonding. This is significant, given maternal representations during pregnancy are predictors of attachment one year postnatally 41 . Furthermore, pregnancy is a critical time for the neurodevelopment of the developing baby. According to the ‘fetal origins hypothesis’ the utero environment can have a sustained impact across the lifespan 42 . Prenatal maternal anxiety can impact the neurobehavioural development of the fetus 43-45 , with long-term effects observed on the child’s cognitive ability 45,46 and emotional adjustment 47 . The findings from this review may have implications for clinical guidance, suggesting a need for early identification and monitoring of psychological distress, with targeted interventions to reduce pregnancy-specific anxiety. These findings hint at the potential value in identifying pregnancy following MAC as a risk factor for emotional vulnerability, which may need to be considered for any future revisions to antenatal and postnatal guidance. However, more studies in this area are required to further support and substantiate this recommendation. Perceived social stigma impacted parents’ relationship to help. Hammarberg et al.’s mixed methods review 5 suggested individuals might “idealise” 5(p.411) parenthood with a reduced sense of entitlement to complain the about the negative aspects of parenting. This review identified this notion both antenatally and postnatally. French et al. 12 referred to this as “self-silencing” 12 (p.574) . Self-silencing or the internalisation of difficulties has been linked to depression 48-50 , lower levels of self-esteem and disturbances in identity 51 . This finding is important given the potential negative consequences for maternal mental-health and the mother-baby relationship 52 . Normalising parental experiences and reducing stigma and shame regarding MAC are important milestones for health services and society to achieve. The transition to parenthood was often complex for expectant parents, facing unique challenges. Maehara et al. (2021) 8 made similar observations in their review, suggesting the acquisition of the maternal identity was delayed, defending against any anticipated disappointments and loss. Individual variability regarding the transition of identity was noted across studies. For some, the transition in identity began at the point of conception 11 , whereas others struggled to realign their old and new identities, needing to physically see and hold their infant to realise their dream of having a baby. Shifts in identity have been linked to anxiety and confusion 53 , making this an important issue to identify, assess and support with. This review identified the significant role of culture and society in shaping experiences of pregnancy and parenting following MAC. Individual, familial and cultural values, regarding reproduction and gender, impact acceptance of MAC and the transition of identity. The sociocultural context featured heavily in papers written in countries with collectivist cultures, amid societal pressures regarding child-rearing 34,36,39 . Parents felt ostracised by their previous childless identity and stigmatised for their use of MAC, impacting help-seeking from services and their own support networks. Greater acknowledgement of the sociocultural factors impacting expectant parents are necessary within health services. This meta-synthesis was novel as it qualitatively synthesised the experiences of both parents following MAC. Four of the included papers reviewed the experiences of couples and two focused specifically on the male partner’s experience. The reviewed literature suggested fears of pregnancy loss were less apparent in male partners. However, there was indication of anxiety and hypervigilance was expressed through checking and monitoring the health status of their partner 27 . A sense of growing responsibility was reported for both parents; with male partners expressing this via acts of protection towards the gestating partner antenatally. This suggests a potential need for health services to monitor the emotional well-being of both parents following MAC. From the studies that explored the father’s perspective, there were suggested differences in the approaches to parenting across parental couples, with the males self-identifying as more ‘relaxed’ and ‘playful’. This meta-synthesis enhanced and extended the findings of Maehara et al. 8 , identifying that individuals’ conception journey persisted into parenthood, leading to acts of protection. These acts of protection may be individuals’ attempts to reclaim an internal locus of control 54 to combat the uncertainty and loss of control during MAC and pregnancy. Quantitative studies have reported varied responses in adjustments to parenting 5 , with a suggestion of no differences compared to spontaneously conceiving mothers 55 . However, the reviewed qualitative literature suggests a need to provide idealised and “ perfect care ” 32,36 with high levels of psychological investment in their child. According to Meighan’s Becoming a Mother Theory 56 , parents or mothers mostly are required to establish responsibilities and boundaries for themselves and their baby. Failure to integrate and process their conception journey may impact this process, leading to over-involved, over-protective, permissive parenting styles with the potential for enmeshment 57 and co-dependency 58 , affecting attachment 59 , the infant’s sense of autonomy 57 , potentially hindering their social and emotional development 60-62 . Furthermore, it highlighted that parents’ experiences of MAC impacted decisions regarding future family formation. Strengths and limitations The meta-synthesis approach allows for new interpretation of multiple findings, which can be used to inform clinical practice. Scientific rigour and transparency were core features of this review with efforts made to reduce bias at screening, data extraction and quality appraisal, with the incorporation of independent reviewers. This review included studies written in different languages, allowing the incorporation of experiences of individuals from different countries and cultures. Similarities were identified across the included studies, suggesting an acceptance and universality of experiences internationally. The findings explored a broad range of experiences both during pregnancy and parenting, something that has not been achieved before. Whilst this meta-synthesis focused on the experiences of pregnancy and parenting following MAC, some caution is necessary for the interpretations and generalisation of previous findings to this study. The review identified a bias of MAC in the context of subfertility with 19 of the included papers recruiting only participants with a history of fertility challenges. Therefore, it is difficult to disentangle whether their experiences are the result of MAC, subfertility, or an interaction of both. To support scientific rigour, the grey literature was excluded. However, this may have introduced publication bias and excluded additional papers. Although the majority of studies had good methodological quality, thereby enhancing the trustworthiness of findings, none of the included studies sufficiently referred to reflexivity, an essential component in qualitative literature. Only two studies 30,31 received a low quality rating; however, the knowledge extracted from these papers did not heavily influence the overall findings. Despite best efforts to include all relevant results, two studies met all other relevant inclusion criteria but failed to report the method of MAC 63, 64 Thus, it was not possible to ensure that the study sample included individuals pregnant/parenting after advanced MAC techniques (as opposed to after OI/IUI only). Attempts to clarify this information with the authors were unsuccessful. It is possible these studies were relevant to the review but were excluded on this basis. Finally, six articles (two Japanese, four Portuguese) were translated into English. Whilst these were checked for accuracy by native speakers, these were not professional transcribers; therefore, meaning may have been lost in translation. There was a lack of consistency across papers in reporting the ethnicity of participants. Additionally, when ethnicity was reported, most participants were from white backgrounds. Therefore, the views of parents from black and minority ethnic (BAME) groups remain under-represented in the literature. Research implications Whilst the findings identify the challenges and difficulties experienced by groups of parents, further research is necessary to determine what kind of support individuals find helpful during pregnancy and parenting. As this review identified a significant bias towards MAC in the context of infertility, further research is necessary with mixed samples or those who sought MAC for alternate reasons, such as being in a same-sex couple or a solo parent. Qualitatively exploring the perspectives of these individuals would allow a more holistic picture, further disentangling the impact of MAC and infertility on experience. Furthermore, the views and experiences of parents from BAME backgrounds are under-represented in the current literature, which is a priority for future research. Clinical implications As part of this systematic review, the psychological, social and health care needs of individuals during pregnancy and parenting following MAC were extracted and synthesised, with suggested clinical recommendations (Table 4). Table 4: Psychological, social and health care needs of parents following MAC with clinical recommendations Needs Clinical recommendations Psychological Potential anxiety in pregnancy. · Increased awareness of potential psychological distress and adjustment difficulties amongst health professionals in maternity services who provide care for individuals pregnant after MAC. · Psychological service provision which validates the potential psychological challenges within this client group · Clinical Health Psychologists embedded within maternity services to disseminate psychological thinking, provide containment and intervention on an individual and systemic level. · Training for health professionals in identifying, monitoring and screening of emotional well-being for all individuals who successfully achieve pregnancy following MAC. · The offer of psychological support during MAC and resultant pregnancy to help individuals integrate and process their experiences, if required. · Consideration of the longer-term psychological needs to be considered incorporating difficulties relating to transition in identity and role. This could be achieved via psychologically informed antenatal and parenting groups or the offer of one-to-one therapeutic sessions focusing on the parent-infant relationship and bond. Social The possibility of feeling excluded and marginalised. Possible reluctance to share distress and experiences due to fear of judgement, shame and stigma. · Normalisation and peer support groups to be offered to help reduce feelings of exclusion. · Incorporation of sociocultural factors such as religious values and beliefs when conducting assessment · Individuals to be signposted to appropriate support services, if required. Healthcare Reassurance and containment. · Promotion of consistency of care with MAC-aware midwives (in the absence of indication for consultant led care) antenatally and postnatally where individuals can develop trusting relationships with familiar health professionals · Specialist training provided to midwives and consultants in relation to pregnancy and parenting after medicalised conception and infertility. · Health professionals to be proactive in fostering non-judgemental spaces, enquiring about the impact of MAC, validating experiences. Conclusions This review highlights the significant psychosocial impact of MAC impacting antenatal and early parenting experiences, exacerbated by the sociocultural context. As evidenced, this can lead to unmet care needs, delayed help-seeking and acts of protection. A need for increased monitoring of parents’ emotional well-being and adjustment to pregnancy and parenting is required. Continuity of care and specialist training for health professionals is necessary to ensure services identify and meet the needs of those who successfully conceive via MAC. Declarations Ethics approval and consent to participate Not applicable. As this was a review of published papers, it did not require ethical approval or participant consent. Consent for publication All authors consent for this review to be published. Availability of data and materials Not applicable. Competing interests The authors declare that they do not have any competing interests. Funding Not applicable. Authors' contributions ZF: Conceptualization, methodology, formal analysis, investigation, writing-original draft, visualisation, project administration. LH: Conceptualisation, methodology, writing – review and editing. DS: Conceptualisation, methodology, formal analysis, writing – review and editing. AW: Conceptualisation, methodology, investigation, writing – review and editing, supervision. Acknowledgments The research team acknowledge the work of Emmeline Joyce for her role within the screening process. Similarly, Farhan Rahman is acknowledged for his role in the quality appraisal and Zaynab Khan for her assistance with the final formatting of this manuscript. Farhan and Zaynab were associated with the Perinatal Mental Mental Health and Parenting (PRIME) Research Unit within Greater Manchester Mental Health NHS Foundation Trust. References Human Fertilisation and Embryology Authority (2019, May). Fertility treatment 2017: trends and figures. https://www.hfea.gov.uk/media/2894/fertility-treatment-2017-trends-and-figures-may-2019.pdf . Centre for Disease Control and Prevention. (2021). Assisted Reproductive Technology: Fertility Clinic and National Summary Report. Accessed 11/12/2021: https://www.cdc.gov/art/reports/2019/pdf/2019-Report-ART-Fertility-Clinic-National-Summary-h.pdf Wyns, C., De Geyter, C., Calhaz-Jorge, C., Kupka, M. 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14:38:24","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":16595,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1ENTREQ.docx","url":"https://assets-eu.researchsquare.com/files/rs-2136464/v1/85b5884ec5819a074c472a70.docx"},{"id":28176400,"identity":"5f9cc9b1-e70d-4958-bc4b-4765ed57bfc8","added_by":"auto","created_at":"2022-10-24 14:38:24","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":25947,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix2matrixofthemes.docx","url":"https://assets-eu.researchsquare.com/files/rs-2136464/v1/eb19a6b9a4a8dfb1bc6f6d01.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Parents' experiencees of life after medicalised conception: A systematic review and thematic meta-synthesis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMedicalised conception (MAC) assists individuals in achieving pregnancy. MAC is an umbrella term which encompasses many different types of treatment including In-Vitro Fertilisation (IVF), Intracytoplasmic Sperm Injection (ICSI), Donor Insemination and Gamete Intrafallopian Transfer\u003csup\u003e1\u003c/sup\u003e. Most individuals who seek MAC are heterosexual couples with fertility challenges (96%)\u003csup\u003e1\u003c/sup\u003e. However, family structures are changing with an increase in same-sex couples and individuals without a partner pursuing MAC.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe prevalence of MAC is rising year on year, for example, with IVF birth rates three times higher in the United Kingdom (UK) when compared to 1991\u003csup\u003e1\u003c/sup\u003e. In 2019, 2.1% of all births in the United States resulted from MAC\u003csup\u003e2\u003c/sup\u003e, similar statistics are seen in many other countries \u003csup\u003e3,4\u003c/sup\u003e. MAC is often not a singular event but a repeated cumulative process\u003csup\u003e5\u003c/sup\u003e. The physical and emotional demands of MAC are well documented in the literature, impacting on subsequent antenatal and postnatal experiences when conception is achieved\u003csup\u003e5-7\u003c/sup\u003e. A previous quantitative\u003csup\u003e7\u003c/sup\u003e and mixed method systematic review\u003csup\u003e5\u003c/sup\u003e described the evidence base as \u0026ldquo;emergent\u0026rdquo;\u003csup\u003e5 (p.411)\u003c/sup\u003e. Consistent reports of increased pregnancy-specific anxiety\u003csup\u003e5,7\u003c/sup\u003e and preoccupation regarding the health and safety of the developing baby have been identified\u003csup\u003e5\u003c/sup\u003e. Internationally, there is a growing body of qualitative literature exploring pregnancy and parenting following MAC. A qualitative systematic review of seven studies conducted by Maehara et al. (2021)\u003csup\u003e8\u003c/sup\u003e explored the antenatal experiences of individuals who conceived via MAC. They confirmed fears regarding pregnancy loss and suggested individuals avoided developing a maternal identity to protect themselves against anticipated disappointment. Furthermore, they found changes to lifestyle\u003csup\u003e9,10\u003c/sup\u003e, an increased need for reassurance\u003csup\u003e6\u003c/sup\u003e, often viewing themselves differently to spontaneously conceiving mothers\u003csup\u003e11,12\u003c/sup\u003e. Despite this, in the UK, fertility treatment is not recognised as a risk factor for adverse perinatal mental health\u003csup\u003e13\u003c/sup\u003e, with parents recommended to receive routine antenatal and postnatal care. Understanding the psychological, social and healthcare needs of this population is essential to ensure services appropriately meet the emotional care needs of parents following MAC.\u003c/p\u003e\n\u003cp\u003eThe current literature\u003csup\u003e7,8\u003c/sup\u003e focuses predominately on the antenatal experiences of the gestating partner experience. In addition, there is also evidence of\u0026nbsp;hypervigilance and feelings of exclusion amongst fathers following MAC\u003csup\u003e14\u003c/sup\u003e. The current review is necessary to expand understanding regarding the transition to parenthood, incorporating postnatal experiences. To allow a more holistic examination of the qualitative literature, this systematic review aimed to synthesise and appraise the qualitative literature examining both parents\u0026rsquo; experiences of pregnancy and parenthood, following MAC. This review also aimed to extract the psychological, social, and healthcare needs of parents, identifying clinical recommendations to enhance future service provision.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA systematic review and meta-synthesis, informed by the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines\u003csup\u003e15\u003c/sup\u003e was conducted. The protocol was registered with PROSPERO on 2/08/2021 (REF: CRD42021269664).\u003c/p\u003e\n\u003ch3\u003eSearch strategy\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eThe Sample, Phenomenon of Interest, Design, Evaluation, Research type (SPIDER)\u003csup\u003e16\u003c/sup\u003e framework for qualitative synthesis was used to develop a systematic search strategy (see Table 1). Electronic searches were conducted in\u0026nbsp;five databases: MEDLINE, PsycINFO, EMBASE, CINAHL and Web of Science in April 2021, with no restrictions on publication date. Due to the multi-disciplinary nature of MAC, database selection ensured study detection from psychological, medical and nursing literature. \u0026nbsp;Search terms were informed by the titles and abstracts of key papers and reviews. \u0026nbsp; Truncation and Boolean operators were utilised to combine searches for individual databases.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;1: Search strategy and terms\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"601\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"7.833333333333333%\"\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.166666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSPIDER framework\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"67%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSearch terms used\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"7.833333333333333%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.166666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSample\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(S)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"67%\"\u003e\n \u003col start=\"1\"\u003e\n \u003cli\u003ePregnan* OR Antenatal* OR Postnatal OR Postpartum OR Early paren*OR Transition\u003c/li\u003e\n \u003c/ol\u003e\n \u003col start=\"2\"\u003e\n \u003cli\u003eParent* OR Mother* OR women OR woman OR partner* OR Lone paren* OR same sex couples OR Same sex parent* OR couples OR infertile couples\u003c/li\u003e\n \u003c/ol\u003e\n \u003col start=\"3\"\u003e\n \u003cli\u003eSubfertility OR infertility OR genetic pre-implantation OR blood borne\u0026nbsp;\u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003ea \u0026ndash; c connected with AND\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"7.833333333333333%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.166666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePhenomenon of Interest\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(PI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"67%\"\u003e\n \u003cp\u003eAssisted reproductive techn* OR Assisted reproductive treatment* Assisted reproduction OR ART OR Medicalised conception OR Medically assisted conception OR MAC OR Medicalized conception OR In Vitro Fertilisation OR In Vitro Fertilization OR IVF OR Intracytoplasmic Sperm Injection OR ICSI or Assisted conception OR Fertility treatmen*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"7.833333333333333%\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.166666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(D)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"67%\"\u003e\n \u003cp\u003equestionnaire* OR survey* OR interview* OR focus group* OR case stud* OR observ*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"7.833333333333333%\"\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.166666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003eEvaluation/outcome\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(E)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"67%\"\u003e\n \u003cp\u003ePsychological outcomes:\u003c/p\u003e\n \u003cp\u003ePsycho* OR Emotional well-being OR Emotional adaptation OR anxiety OR pregnancy specific anxiety OR self-esteem OR self-confidence OR depression OR low mood OR stress OR trauma OR adjustment OR attachment\u003c/p\u003e\n \u003cp\u003eSocial Outcomes:\u003c/p\u003e\n \u003cp\u003eMarital discord OR marital satisfaction OR marital relationship OR relationship OR social OR social functioning OR attitudes OR parent-infant relationship OR meaning of mothering OR perceptions\u003c/p\u003e\n \u003cp\u003eHealthcare outcomes:\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ehealthcare OR antennal care OR antenatal need* OR postnatal care OR Postnatal need* OR childbirth OR birth\u003c/p\u003e\n \u003cp\u003ePsychological, social and healthcare outcomes connected by \u0026lsquo;OR\u0026rsquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"7.833333333333333%\"\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.166666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003eResearch type\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(R)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"67%\"\u003e\n \u003cp\u003eQualitative OR Experience* OR Narrativ* OR Interpretative Phenomenological Analysis OR IPA OR lived experience* OR Thematic Analysis OR Grounded Theory OR Content analysis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003eThe above were connected in the following way: S AND PI AND D AND E AND R\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e* Truncation used to broaden search terms\u0026nbsp;to include\u0026nbsp;various word endings and spellings.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eReferences were exported to Endnote Reference Managing software (Clarivate Analytics UK Ltd [version 20], 2020) removing duplicates. Titles and abstracts were screened against inclusion criteria by the first author. Full text versions of retained articles were assessed for eligibility. Database searches were supplemented by forward and backward\u0026nbsp;searching the reference lists of included studies. \u0026nbsp;To reduce bias, an independent researcher, not attached to the research team, checked 15% of titles, abstracts and full-text papers for inclusion; 100% agreement was achieved. All authors were involved in the final decision of papers included in this review.\u003c/p\u003e\n\u003ch3\u003eInclusion criteria for studies\u003c/h3\u003e\n\u003cp\u003eStudies were included if they 1) were an empirical study that used qualitative methods to explore and analyse gestating individuals and/or their partners\u0026rsquo; experiences of pregnancy and parenting following successful MAC (i.e., studies were included even if only one parent reported their experiences), 2) were published in a peer-reviewed journal, 3) focused\u0026nbsp;on MAC treatments, such as IVF, ICSI, Gamete Intrafallopian Transfer and the use of donor gametes. Those that specifically focused on Intrauterine Insemination (IUI) or Ovulation Induction (OI) were excluded due to their less invasive nature. However, mixed samples of MAC and IUI or OI were retained. Studies meeting the inclusion criteria published in any language were included and translated where possible.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGrey literature was excluded. Studies were also excluded when they deviated from the experience of MAC itself and focused on specific topics, such as fertility, same-sex parenting, use of donor gametes or surrogacy and when they did not focus on the parents\u0026rsquo; perspective or lived experiences, for example, only reporting professional views. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eMethodological quality and risk of bias assessment\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eAll studies were assessed for methodological quality using the Critical Appraisal Skills Programme (CASP)\u003csup\u003e17\u003c/sup\u003e qualitative checklist. The CASP is widely employed quality assessment tool in qualitative health-related synthesis\u003csup\u003e18\u003c/sup\u003eand includes questions relating to study validity, design and results. A numerical value was prescribed to checklist items (No = 0, Can\u0026rsquo;t Tell = 0.5, Yes = 1) to generate a useful indicator for comparison, an approach adopted in a previous meta-synthesis\u003csup\u003e19\u003c/sup\u003e. The total CASP score for each paper was then categorised as either \u0026lsquo;high\u0026rsquo; (\u0026gt;8-10), \u0026lsquo;moderate\u0026rsquo; (6-8) or \u0026lsquo;low\u0026rsquo; (\u0026nbsp;5) quality. An independent reviewer rated 50% of the included papers to assess reliability, with any disagreements being resolved through discussion.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eData extraction and synthesis approach\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eRelevant data were extracted from the studies and tabulated chronologically according to antenatal experience, postnatal experience or studies covering both.\u0026nbsp;A\u0026nbsp;thematic synthesis was adopted allowing for new interpretation of multiple findings and the development of analytical themes, furthering understanding\u003csup\u003e20,21\u003c/sup\u003e. A critical realist perspective position was adopted as the epistemological stance\u003csup\u003e22\u003c/sup\u003e due to its focus on understanding, rather than describing phenomena. Central to the critical realist position is integrating ontology, (what is real independent of our perceptions?) with constructivist epistemology\u003csup\u003e23\u003c/sup\u003e. \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;All text under the original papers\u0026rsquo; \u0026lsquo;Results\u0026rsquo; or \u0026lsquo;Findings\u0026rsquo; headings were extracted into NVivo software (QSR International Pty Ltd., 2020). The first author undertook the stages of thematic synthesis\u003csup\u003e16\u003c/sup\u003e. This included line-by-line coding, the development of descriptive themes and analytical themes. Firstly, each line of the primary study\u0026rsquo;s findings was coded according to meaning and content. Following this, studies were coded into pre-existing codes and new codes created when required. The first author looked for similarities and differences between the codes and they were grouped into related areas to develop descriptive themes. Codes were identified within and across studies and collated based on coherence. Analytical themes were then developed inductively by synthesising the findings across studies, interpreting their meaning. \u0026nbsp;An experienced qualitative post-doctoral researcher scrutinised the data to ensure codes and themes were appropriately derived from the data and were acceptable. All themes and subthemes were discussed, refined and agreed by all authors. \u0026nbsp;The Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) checklist\u003csup\u003e24\u003c/sup\u003e (see Appendix 1) was also completed. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eReflexivity statement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eReflexivity is a central component of qualitative research as the researchers\u0026rsquo; assumptions, beliefs and prior experiences, both personal and professional, influence the research process. Acknowledgement of the researchers\u0026rsquo; reflexive position enhances rigour, credibility and extends understanding of the findings\u003csup\u003e25\u003c/sup\u003e. The academic research team comprised of four white British and/or European women who had a wealth of clinical, academic and lived experience. All research team members had a firm philosophy in patient-centred, preventative care and a shared interest in understanding the psychological factors impacting expectant and new parents. \u0026nbsp;The first author was a practising Trainee Clinical Psychologist who had experience of working antenatally and postnatally with expectant and new parents experiencing relational difficulties. DS was an experienced Health Psychologist and AW a Clinical Psychologist and researcher, with particular interests in parenting and maternal mental health during the perinatal period. LH was an expert, working clinically and in a research capacity, in the field of Obstetrics, bringing a medical perspective. \u0026nbsp;All members of the research team were mothers with varying experiences of conception, including IVF, pregnancy, and loss.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The first author kept a reflective log throughout the research process. Interpretations were shared between the first author and DS, challenging each other\u0026rsquo;s pre-conceptions, allowing new meaning to be distilled. Regular discussions amongst the research team were had regarding the interpretation of data, reflecting on our positioning, challenging our own biases and beliefs.\u003c/p\u003e"},{"header":"Results","content":"\u003ch3\u003eStudy characteristics\u003c/h3\u003e\n\u003cp\u003eFrom an initial 2,513 search results, 20 qualitative studies, based on 19 samples were included in the review (see Figure 1). The studies represented the experiences of 300 individuals. Most studies were conducted in Asia (n=7) and Europe (n=7) followed by, South America (n=5), and Australia (n=1). Six studies were translated to English using an online service (www.online doctranslator.com) and checked for accuracy by native speakers.\u0026nbsp; The average sample size was 15, ranging from 3 to 51 participants. The studies captured the views of mothers/expectant mothers (n=13), fathers/expectant fathers (n=2) and couples (n=5), antenatally (n=12), postnatally (n=4) or their experiences of both (n=4).\u0026nbsp; Many studies explored participants\u0026rsquo; views and experiences of pregnancy and parenting more generally (n=16). Some studies focussed on breastfeeding (n=1), the couple\u0026rsquo;s relationship (n=1), physical activity (n=1) and the midwifery care needs of participants (n=1). Table 2 summarises the study characteristics.\u003c/p\u003e\n\u003cp\u003eTable 2: Overview of all 20 included studies\u003c/p\u003e\n\u003ctable width=\"954\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"35\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors and location\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e\u003cstrong\u003eAims\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"181\"\u003e\n\u003cp\u003e\u003cstrong\u003eParticipant demographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eMAC detail \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"227\"\u003e\n\u003cp\u003e\u003cstrong\u003eMain themes\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"6\" width=\"822\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudies exploring the antenatal period and birth\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"35\"\u003e\n\u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eDornelles, MacCallum, Lopes, Piccinini and Passos (2016)\u003csup\u003e35\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBrazil\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eTo understand the perceptions of pregnancy achieved after ART\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhether the above experience is affected by previous failed treatment cycles.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eSemi-structured interviews\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(Length approximately 90 minutes)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"181\"\u003e\n\u003cp\u003e19 expectant first-time mothers in the third trimester of pregnancy\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean age\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e35 years (range 25-44)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhite = 16 (89%|)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMarried = 12 (63%)\u003c/p\u003e\n\u003cp\u003eCohabiting = 7 (37%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUniversity degree = 12 (63%)\u003c/p\u003e\n\u003cp\u003eHigh school = 7 (37%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePregnancy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSingleton = 15 (79%)\u003c/p\u003e\n\u003cp\u003eTwins = 1(5%)\u003c/p\u003e\n\u003cp\u003eTriplets = 3 (16%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eMAC indication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFemale = 15 (79%)\u003c/p\u003e\n\u003cp\u003eMale = 2 (10.5%)\u003c/p\u003e\n\u003cp\u003eCombined = 1 (5.3%)\u003c/p\u003e\n\u003cp\u003eUnexplained = 1 (5.3%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC type\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIVF = 15 (79%)\u003c/p\u003e\n\u003cp\u003eOI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eIUI =3 (16%)\u003c/p\u003e\n\u003cp\u003eNot specified\u003csup\u003e a\u003c/sup\u003e =1 (5%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC treatment history\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFirst attempt =11 (57%)\u003c/p\u003e\n\u003cp\u003eTwo or more attempts = 8 (43%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eThematic analysis\u003c/p\u003e\n\u003cp\u003e(Laville \u0026amp; Dionne 1999)\u003csup\u003e65\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"227\"\u003e\n\u003cp\u003eThree main themes:\u003c/p\u003e\n\u003cp\u003e1)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Tolerance of the demands of treatment/pregnancy\u003c/p\u003e\n\u003cp\u003e2)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Consideration of the mechanics of treatment and pregnancy\u003c/p\u003e\n\u003cp\u003e3)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Emotionally painful aspects of treatment/pregnancy\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"35\"\u003e\n\u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eSonego., Dornelles, Lopes, Piccinini and Passos\u003c/p\u003e\n\u003cp\u003e(2017)\u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBrazil\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eTo investigate the experience of pregnancy after ART from the father\u0026rsquo;s perspective.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eSemi-structured interview using the \u003cem\u003ePregnancy and Expectations of the Future Father\u0026nbsp;\u003c/em\u003e(NUDIF, 1998b\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(Length approximately 90 minutes)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"181\"\u003e\n\u003cp\u003e13 men whose partners were in the 3\u003csup\u003erd\u003c/sup\u003e trimester of pregnancy\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean age\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported (range = 32-46 years)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMarried or cohabiting = 13 (100%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eElementary school = 2 (15%)\u003c/p\u003e\n\u003cp\u003eHigh school = 4 (31%)\u003c/p\u003e\n\u003cp\u003eIncomplete higher education = 1 (8%)\u003c/p\u003e\n\u003cp\u003eCompleted higher education = 6 (46%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePregnancy \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSingle = 10 (77%)\u003c/p\u003e\n\u003cp\u003eMultiple = 3 (23%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eMAC indication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFemale = 9 (69%)\u003c/p\u003e\n\u003cp\u003eMale = 3 (23%)\u003c/p\u003e\n\u003cp\u003eCombined = 1 (8%)\u003c/p\u003e\n\u003cp\u003eUnexplained = 0 (0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC type\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIVF = 9 (70%)\u003c/p\u003e\n\u003cp\u003eOI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eIUI = 2 (15%)\u003c/p\u003e\n\u003cp\u003eNot specified\u003csup\u003e a\u003c/sup\u003e = 2 (15%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC treatment history\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFirst attempt = 7 (54%)\u003c/p\u003e\n\u003cp\u003eTwo or more attempts\u003csup\u003e b\u003c/sup\u003e = 6 (46%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eContent analysis\u003c/p\u003e\n\u003cp\u003e(Laville \u0026amp; Dionne, 1999)\u003csup\u003e65\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"227\"\u003e\n\u003cp\u003eTwo main themes:\u003c/p\u003e\n\u003cp\u003e1)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Subjective experience of the father during pregnancy\u003c/p\u003e\n\u003cp\u003e2)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Effects of treatment on the experience of pregnancy\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"35\"\u003e\n\u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eWalker, Mills and Gilchrist (2017)\u003csup\u003e10\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUK\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eTo explore the qualitative experiences and decision-making processes regarding physical activity in women who have undergone IVF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eIndividual semi-structured interviews\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(Length not reported)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"181\"\u003e\n\u003cp\u003e8 women who had successfully conceived via IVF/ICSCI in the last two years\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean age\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e33 years old (range = 24-39)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthnicity \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhite British = 8 (100%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePregnancy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eMAC indication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC type\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIVF = 8 (100%)\u003c/p\u003e\n\u003cp\u003eOI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eIUI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eNot specified = 0 (0%)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC treatment history\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eInterpretative Phenomenological Analysis (IPA; Smith, Flowers \u0026amp; Larkin, 2009)\u003csup\u003e66\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"227\"\u003e\n\u003cp\u003eThree main themes\u003c/p\u003e\n\u003cp\u003e1)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Navigating away from childlessness and towards motherhood\u003c/p\u003e\n\u003cp\u003e2)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Negotiating a safe passage\u003c/p\u003e\n\u003cp\u003e3)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Balancing the challenges of pregnancy with the needs of the self\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"35\"\u003e\n\u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eWarmelink, Adema, Pranger and Paul de Cock (2016)\u003csup\u003e40\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNetherlands\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eTo investigate the midwifery care needs during pregnancy of couples or women who have conceived as a result of fertility treatment.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eSemi-structured, in-depth interviews\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(Average length 55 minutes. Ranged from 28-91 minutes)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"181\"\u003e\n\u003cp\u003e9 interviews with 11 participants (two couples: Female = 9;\u003c/p\u003e\n\u003cp\u003eMale = 2)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean age\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFemale mean age = 34.1 years (range = 32-38 years)\u003c/p\u003e\n\u003cp\u003eMale mean age = 33.5 years (range = 32 -35 years)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDutch = 100%\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducatio\u003c/strong\u003en\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePregnancy \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eMAC indication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFemale = 2 (22%)\u003c/p\u003e\n\u003cp\u003eMale = 4 (44%)\u003c/p\u003e\n\u003cp\u003eCombined = 1 (11%)\u003c/p\u003e\n\u003cp\u003eUnexplained = 2 (22%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC type\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIVF = 10 (91%)\u003c/p\u003e\n\u003cp\u003eOI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eIUI = 1 (9%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC treatment history\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eContent analysis (Boeije, 2008)\u003csup\u003e67\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"227\"\u003e\n\u003cp\u003eFour main themes:\u003c/p\u003e\n\u003cp\u003e1)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Normal but not normal: Paradoxical feelings\u003c/p\u003e\n\u003cp\u003e2)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Understanding the impact of previous history\u003c/p\u003e\n\u003cp\u003e3)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Psychosocial support\u003c/p\u003e\n\u003cp\u003e4)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Care needs in general\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"35\"\u003e\n\u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eFrench, Sharp and Turner (2015)\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUK\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eTo explore the antenatal experiences of males and females who have successfully conceived via fertility treatment\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eIndividual interviews\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(Length approximately 1-3 hours)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"181\"\u003e\n\u003cp\u003e20 participants\u003c/p\u003e\n\u003cp\u003e12 females; 8 males interviewed at 28 weeks\u0026rsquo; gestation of first pregnancy\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean age\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e(Age range = 35-39 years)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarital status \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePregnancy \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eMAC indication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFemale = 7 (35%)\u003c/p\u003e\n\u003cp\u003eMale = 6 (30%)\u003c/p\u003e\n\u003cp\u003eCombined = 2 (10%)\u003c/p\u003e\n\u003cp\u003eUnexplained = 5 (25%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC type\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIVF = 17 (85%)\u003c/p\u003e\n\u003cp\u003eOI = 2 (10%)\u003c/p\u003e\n\u003cp\u003eIUI = 1 (5%)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC treatment history\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eThematic analysis- constant comparison (Patton, 1990)\u003csup\u003e69\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"227\"\u003e\n\u003cp\u003eFour main themes:\u003c/p\u003e\n\u003cp\u003e1)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Fear of pregnancy loss\u003c/p\u003e\n\u003cp\u003e2)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Difficulty adjusting to pregnancy and planning for parenthood\u003c/p\u003e\n\u003cp\u003e3)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Gaps in care\u003c/p\u003e\n\u003cp\u003e4)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Self-silencing\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"35\"\u003e\n\u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eRanjbar, Akhondi, Borimnejad, Ghaffari and Behboodi-Moghadam (2015)\u003csup\u003e9\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIran\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eTo explore how women make sense of assisted pregnancy in Iranian culture and context\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eSemi-structured, interviews\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(Length approximately 30-60 minutes)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"181\"\u003e\n\u003cp\u003e12 women who experiences assisted pregnancy with their first child\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean age\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e29.51 (Age range = 24-36)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIranian\u003c/p\u003e\n\u003cp\u003eKurd = 2 (17%)\u003c/p\u003e\n\u003cp\u003eFars = 6 (50%)\u003c/p\u003e\n\u003cp\u003eTurk = 3 (25%)\u003c/p\u003e\n\u003cp\u003eLor = 1 (8%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e100% married\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMSc/MA = 2 (16.7%)\u003c/p\u003e\n\u003cp\u003eBS = 3 (25%)\u003c/p\u003e\n\u003cp\u003eHigh School = 6 (50%)\u003c/p\u003e\n\u003cp\u003e9\u003csup\u003eth\u003c/sup\u003e grade = 1 (8%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePregnancy \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSingle = 12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eMAC indication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFemale =12 (100%)\u003c/p\u003e\n\u003cp\u003eMale = 0 (0%)\u003c/p\u003e\n\u003cp\u003eCombined = 0 (0%)\u003c/p\u003e\n\u003cp\u003eUnexplained = 0 (0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC type\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIVF = 12 (100%)\u003c/p\u003e\n\u003cp\u003eOI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eIUI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eNot specified = 0 (0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC treatment history\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eInterpretative Phenomenological approach (Van Manen, 1990)\u003csup\u003e70\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"227\"\u003e\n\u003cp\u003eThree main themes:\u003c/p\u003e\n\u003cp\u003e1)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Finding peace in life\u003c/p\u003e\n\u003cp\u003e2)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Paradoxical feelings\u003c/p\u003e\n\u003cp\u003e3)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Struggling to realise a dream\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"35\"\u003e\n\u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eDornelles, MacCallum, Lopes, Piccinini and Passos (2014)\u003csup\u003e33\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBrazil\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eTo explore women\u0026rsquo;s fears during pregnancy following conception via assisted reproductive technology (ART)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eSemi-structured interviews\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(Length approximately 90 minutes)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"181\"\u003e\n\u003cp\u003e19 first time mothers in their third trimester of pregnancy\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean age\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e35 years (range 25-44)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthnicity \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhite = 17 (89%)\u003c/p\u003e\n\u003cp\u003eOther ethnicity = 2 (11%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarital status \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMarried = 12 (63%)\u003c/p\u003e\n\u003cp\u003eCohabiting = 7 (37%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUniversity degree = 12 (63%)\u003c/p\u003e\n\u003cp\u003eHigh School graduates = 7 (37%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePregnancy \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSingle pregnancy = 15 (80%)\u003c/p\u003e\n\u003cp\u003eTwins = 1 (5%)\u003c/p\u003e\n\u003cp\u003eTriplets = 3 (15%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eMAC indication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFemale = 15 (79%)\u003c/p\u003e\n\u003cp\u003eMale = 2 (11%)\u003c/p\u003e\n\u003cp\u003eCombined = 1 (5%)\u003c/p\u003e\n\u003cp\u003eUnexplained = 1 (5%)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC type\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIVF = 15 (79%)\u003c/p\u003e\n\u003cp\u003eOI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eIUI = 3 (16%)\u003c/p\u003e\n\u003cp\u003eNot specified\u003csup\u003e a\u003c/sup\u003e= 1(5%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC treatment history\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFirst attempt = 10 (53%)\u003c/p\u003e\n\u003cp\u003eTwo or more attempts = 9 (47%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eContent Analysis (Laville \u0026amp; Dionne, 1999)\u003csup\u003e65\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"227\"\u003e\n\u003cp\u003eFour main themes:\u003c/p\u003e\n\u003cp\u003e1)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; The baby\u0026rsquo;s survival\u003c/p\u003e\n\u003cp\u003e2)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; The health of the baby\u003c/p\u003e\n\u003cp\u003e3)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; The efficacy of the other\u003c/p\u003e\n\u003cp\u003e4)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Childbirth\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"35\"\u003e\n\u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eLin, Tsai and Lai (2013)\u003csup\u003e34\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTaiwan\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eTo describe the experiences of pregnancy in Taiwanese women who had undergone at least three cycles of ART over a period exceeding three years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eIn-depth interviews\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(Length approximately 90-120 minutes)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"181\"\u003e\n\u003cp\u003e15 females interviewed within one year of delivering a baby\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean age\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e39 years (range 31-44)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMarried = 15 (100%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMSc = 5 (33%)\u003c/p\u003e\n\u003cp\u003eBachelor\u0026rsquo;s degree = 8 (53%)\u003c/p\u003e\n\u003cp\u003eJunior college degree = 1 (7%)\u003c/p\u003e\n\u003cp\u003eHigh School Diploma = 1 (7%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePregnancy \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eMAC indication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFemale factor = 15 (100%)\u003c/p\u003e\n\u003cp\u003eMale factor = 0 (0%)\u003c/p\u003e\n\u003cp\u003eCombined = 0 (0%)\u003c/p\u003e\n\u003cp\u003eUnexplained = 0 (0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC type\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIVF = 15 (100%)\u003c/p\u003e\n\u003cp\u003eOI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eIUI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eNot specified = 0 (0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC treatment history\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFirst attempt = 0 (0%)\u003c/p\u003e\n\u003cp\u003eTwo or more attempts = 15 (100%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003ePhenomenological qualitative method\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eProcedures adopted by Creswell (2009)\u003csup\u003e23\u003c/sup\u003e.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"227\"\u003e\n\u003cp\u003eFive main themes:\u003c/p\u003e\n\u003cp\u003e1)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Emphasis on the safety and health of the foetus\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Psychosocial reactions to physical and physiological conditions\u003c/p\u003e\n\u003cp\u003e3)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Transition of identity\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Insights after going through pregnancy and labour\u003c/p\u003e\n\u003cp\u003e5)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Impact of society on pregnancy\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"35\"\u003e\n\u003cp\u003e\u003cstrong\u003e9\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eSmorti and Smorti (2013)\u003csup\u003e29\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eItaly\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eTo explore the psychological processes that develop in women and men during their first pregnancy obtained with assisted reproduction treatment.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eSemi-structured autobiographical interview\u003c/p\u003e\n\u003cp\u003e(Length approximately (50-90 minutes)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"181\"\u003e\n\u003cp\u003e15 Italian couples pregnant with their first child (29\u003csup\u003eth\u003c/sup\u003e-34 weeks pregnant)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean age\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFemale = 36 years\u003c/p\u003e\n\u003cp\u003eMale = 38 years\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhite = 14 (93%)\u003c/p\u003e\n\u003cp\u003eOther ethnicity = 1 (7%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMarried or cohabiting = 15 (100%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWomen degree or high school = 13 (87%)\u003c/p\u003e\n\u003cp\u003eMen completed secondary school = 13 (86%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eP\u003cstrong\u003eregnancy \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSingle = 12 (80%)\u003c/p\u003e\n\u003cp\u003eTwins = 2 (13%)\u003c/p\u003e\n\u003cp\u003eMultiple pregnancy = 1 (7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eMAC indication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFemale = 6 (40%)\u003c/p\u003e\n\u003cp\u003eMale = 5 (36%)\u003c/p\u003e\n\u003cp\u003eCombined = 1 (4%)\u003c/p\u003e\n\u003cp\u003eUnexplained = 3 (20%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC type\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIVF = 7 (48%)\u003c/p\u003e\n\u003cp\u003eOI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eIUI = 8 (52%)\u003c/p\u003e\n\u003cp\u003eNot specified = 0 (0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC treatment history\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFirst attempt = 6 (40%)\u003c/p\u003e\n\u003cp\u003eTwo or more attempts = 9 (60%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eIdentification of themes, patterns on global and qualitative level.\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"227\"\u003e\n\u003cp\u003eParticipants narrated their pregnancy experience as a process with four main phases:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1\u003csup\u003est\u003c/sup\u003e phase: \u0026lsquo;Doubt\u0026rsquo; phase\u003c/p\u003e\n\u003cp\u003e2\u003csup\u003end\u003c/sup\u003e phase: Anxious and overwhelming need to seek help and support re: fertility\u003c/p\u003e\n\u003cp\u003e3\u003csup\u003erd\u003c/sup\u003e phase: struggle and the victory.\u003c/p\u003e\n\u003cp\u003e4\u003csup\u003eth\u003c/sup\u003e phase: The monitoring phase\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"35\"\u003e\n\u003cp\u003e\u003cstrong\u003e10\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eDornelles and Lopes (2011)\u003csup\u003e30\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBrazil\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eTo understand the process of becoming a mother in the context of ART.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eInterview on Pregnancy and Expectations of the Pregnant women\u003c/p\u003e\n\u003cp\u003e(NUDIF, 1998b)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(Length not reported)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"181\"\u003e\n\u003cp\u003e3 participants in their third trimester of pregnancy with their first child.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean age\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e35 years (range = 25-37)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducation:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHigher education: 2 (67%)\u003c/p\u003e\n\u003cp\u003eMiddle education: 1 (33%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePregnancy \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eMAC indication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFemale = 1 (33%)\u003c/p\u003e\n\u003cp\u003eMale = 1 (33%)\u003c/p\u003e\n\u003cp\u003eCombined = 0 (0%)\u003c/p\u003e\n\u003cp\u003eUnexplained = 1 (33%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC type\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIVF = 1 (33%)\u003c/p\u003e\n\u003cp\u003eOI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eIUI = 1 (33%)\u003c/p\u003e\n\u003cp\u003eNot specified\u003csup\u003e a\u003c/sup\u003e = 1 (33%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC treatment history\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFirst attempt = 1 (33%)\u003c/p\u003e\n\u003cp\u003eTwo or more attempts = 2 (66%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eContent Analysis (Laville \u0026amp; Dionne, 1999)\u003csup\u003e65\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"227\"\u003e\n\u003cp\u003e6 main themes\u003c/p\u003e\n\u003cp\u003e1)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Life growth theme\u003c/p\u003e\n\u003cp\u003e2)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Theme relating to primary\u003c/p\u003e\n\u003cp\u003e3)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Support matrix \u0026ndash;\u003c/p\u003e\n\u003cp\u003e4)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Identity reorganisation \u0026ndash;\u003c/p\u003e\n\u003cp\u003e5)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Stages of conception: pregnancy\u003c/p\u003e\n\u003cp\u003e6)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Imaginary baby\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"35\"\u003e\n\u003cp\u003e\u003cstrong\u003e11\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eSilva and Lopes (2011)\u003csup\u003e37\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBrazil\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eTo investigate the marital relationship during treatment and pregnancy in couples who became pregnant with the help of ART\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eSemi \u0026mdash;structured interviews\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(Length approximately 120 minutes)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"181\"\u003e\n\u003cp\u003e6 participants (three couples)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean age and range\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn a relationship = 6 (100%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHigher education = 4 (67%)\u003c/p\u003e\n\u003cp\u003eElementary school = 2 (33%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePregnancy status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eMAC indication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFemale = 2 (33%)\u003c/p\u003e\n\u003cp\u003eMale = 1 (33%)\u003c/p\u003e\n\u003cp\u003eCombined = 0 (0%)\u003c/p\u003e\n\u003cp\u003eUnexplained = 0 (0%)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC type\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIVF = 2 (66%)\u003c/p\u003e\n\u003cp\u003eOI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eIUI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eNot specified\u003csup\u003e a\u003c/sup\u003e = 1 (33%)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC treatment history\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFirst attempts = 1 (33%)\u003c/p\u003e\n\u003cp\u003eTwo or more attempts = 2 (66%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eContent Analysis (Laville \u0026amp; Dione, 1999)\u003csup\u003e65\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"227\"\u003e\n\u003cp\u003eSix main themes:\u003c/p\u003e\n\u003cp\u003e1)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Cohesion during treatment\u003c/p\u003e\n\u003cp\u003e2)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Cohesion during pregnancy\u003c/p\u003e\n\u003cp\u003e3)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Sexuality during treatment\u003c/p\u003e\n\u003cp\u003e4)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Sexuality during pregnancy\u003c/p\u003e\n\u003cp\u003e5)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Communication during treatment\u003c/p\u003e\n\u003cp\u003e6)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Communication during pregnancy\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"35\"\u003e\n\u003cp\u003e\u003cstrong\u003e12\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eHayashi and Sayama (2009)\u003csup\u003e11\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eJapan\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eTo qualitatively highlight the emotional processes experienced by women who achieved pregnancy via assisted reproductive technology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eSemi-structured interviews\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(Average length = 64.5 minutes; range = 46-87 minutes)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"181\"\u003e\n\u003cp\u003e8 primiparas who achieved pregnancy via ART one to six months after delivery.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean age\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e34 years (age range = 28-42)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducation status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePregnancy status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSingle = 6 (75%)\u003c/p\u003e\n\u003cp\u003eTwins = 2 (25%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eMAC indication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC type\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIVF = 7 (88%)\u003c/p\u003e\n\u003cp\u003eOI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eIUI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eOther = 1 (12%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC treatment history\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003ePhenomenological study method (Colazzi, 1978)\u003csup\u003e70\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"227\"\u003e\n\u003cp\u003eNine main themes:\u003c/p\u003e\n\u003cp\u003e1)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Feelings of mission and pressure by becoming pregnant\u003c/p\u003e\n\u003cp\u003e2)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Attention to the avoided jealousy\u003c/p\u003e\n\u003cp\u003e3)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Wisdom in overcoming anxiety\u003c/p\u003e\n\u003cp\u003e4)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Maternal self-consciousness\u003c/p\u003e\n\u003cp\u003e5)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Release from feelings of loneliness\u003c/p\u003e\n\u003cp\u003e6)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Recovery of self-confidence\u003c/p\u003e\n\u003cp\u003e7)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Positive acceptance of infertility and the treatment experience\u003c/p\u003e\n\u003cp\u003e8)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Confirming one\u0026rsquo;s own growth\u003c/p\u003e\n\u003cp\u003e9)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Feeling authentic joy from pregnancy\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"8\" width=\"954\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudies exploring birth and/or postpartum experiences\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"35\"\u003e\n\u003cp\u003e\u003cstrong\u003e13\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eD\u0026iacute;az S\u0026aacute;ez, Fernandez-Medina, Granero-Molina, Fernandez-Sola, Hernandez-Padilla and Lopez-Rodrugues (2021)\u003csup\u003e28\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSpain\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eTo describe and understand the breastfeeding experiences of first-time mothers who conceived using ART\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eFocus group (n = 8) lasting 86 minutes and\u003c/p\u003e\n\u003cp\u003eIndividual semi-structured\u0026nbsp; interviews (n = 19)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(Average length = 37 minutes.)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"181\"\u003e\n\u003cp\u003e27 women first time mothers\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean age\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e38 years (age range = not reported)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMarried = 21 (78%)\u003c/p\u003e\n\u003cp\u003eCohabiting = 6 (22%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHigher Education = 15 (56%)\u003c/p\u003e\n\u003cp\u003eMedium = 2 (7%)\u003c/p\u003e\n\u003cp\u003eBasic = 10 (37%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePregnancy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSingle = 27 (100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eMAC indication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC type\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIVF = 16 (59%)\u003c/p\u003e\n\u003cp\u003eOI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eIUI = 11 (41%)\u003c/p\u003e\n\u003cp\u003eNot specified = 0 (0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC treatment history\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eHermeneutic phenomenology (Gadamer, 2005)\u003csup\u003e71\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"227\"\u003e\n\u003cp\u003eTwo main themes:\u003c/p\u003e\n\u003cp\u003e1)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; The transition from infertility to motherhood\u003c/p\u003e\n\u003cp\u003e2)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; The reality of becoming a breastfeeding mother after ART\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"35\"\u003e\n\u003cp\u003e\u003cstrong\u003e14\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eSadeghi, Mohammadi, Mohammadpourand and Abbasi (2019)\u003csup\u003e39\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIran\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eTo investigate the challenges mothers face after assisted-reproduction techniques\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePart of a larger phenomenological study that aimed to discover the experience of motherhood after ART\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eSem- structured interviews,\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(Length not report)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"181\"\u003e\n\u003cp\u003e13 mothers who conceived via ART\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean age\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e32 years\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarital status \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Reported\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDiploma = 7 (54%)\u003c/p\u003e\n\u003cp\u003eBachelor = 6 (46%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePregnancy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eMAC indication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFemale = 8 (62%)\u003c/p\u003e\n\u003cp\u003eMale = 5 (38%)\u003c/p\u003e\n\u003cp\u003eCombined = 0 (0%)\u003c/p\u003e\n\u003cp\u003eUnexplained = 0 (0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC type\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIVF = 9 (69%)\u003c/p\u003e\n\u003cp\u003eOI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eIUI = 3 (31%)\u003c/p\u003e\n\u003cp\u003eNot specified = 0 (0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC treatment history\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eHermeneutic Phenomenological method incorporating thematic analysis\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(Van Manen, 1990)\u003csup\u003e69\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"227\"\u003e\n\u003cp\u003eOne main theme:\u003c/p\u003e\n\u003cp\u003e1)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026lsquo;Over-challenged mother\u0026rsquo;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"35\"\u003e\n\u003cp\u003e\u003cstrong\u003e15\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eMohammadi, Shamshiri, Mohammadpour, Vehilainen-Julkunen, Abbasi and Sadeghi (2015)\u003csup\u003e36\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIran\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eTo explore and describe the experience and meaning of mothering after ART among Iranian women\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eSemi structured interviews\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(Length approximately 45-70 minutes)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"181\"\u003e\n\u003cp\u003e9 first time mothers\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean age\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e32 years (age range = 28-45)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot report\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDiploma = 6 (67%)\u003c/p\u003e\n\u003cp\u003eBachelor = 3 (33%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePregnancy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eMAC indication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFemale = 6 (67%)\u003c/p\u003e\n\u003cp\u003eMale = 3 (33%)\u003c/p\u003e\n\u003cp\u003eCombined = 0 (0%)\u003c/p\u003e\n\u003cp\u003eUnexplained = 0 (0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC type\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIVF = 6 (67%)\u003c/p\u003e\n\u003cp\u003eOI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eIUI = 3 (33%)\u003c/p\u003e\n\u003cp\u003eNot specified = 0 (0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC treatment history\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eHeideggerian hermeneutic Phenomenological approach (cited in Van Manen, 1990)\u003csup\u003e69\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"227\"\u003e\n\u003cp\u003eOne main theme:\u003c/p\u003e\n\u003cp\u003e1) \u0026lsquo;Super-mothering\u0026rsquo;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"35\"\u003e\n\u003cp\u003e\u003cstrong\u003e16\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eBracks- Zalloua, McMahon and Gibson (2011)\u003csup\u003e38\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAustralia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eTo provide an in-depth understanding of early parenthood for IVF-conceiving fathers\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eSemi-structured interviews\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(Length approximately one hour)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"181\"\u003e\n\u003cp\u003e8 men whose partners had conceived via IVF\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean age\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e40 years old (range 29-53 years)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMarried = 7 (88%)\u003c/p\u003e\n\u003cp\u003eCohabiting = 1 (12%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWestern = 8 (100%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePregnancy \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eMAC indication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFemale = 4 (50%)\u003c/p\u003e\n\u003cp\u003eMale = 4 (50%)\u003c/p\u003e\n\u003cp\u003eCombined = 0 (0%)\u003c/p\u003e\n\u003cp\u003eUnexplained = 0 (0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC type\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIVF = 8 (100%)\u003c/p\u003e\n\u003cp\u003eOI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eIUI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eNot specified = 0 (0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC treatment history\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eModified Analytic Induction (Bogdan \u0026amp; Biklem, 1998)\u003csup\u003e72\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"227\"\u003e\n\u003cp\u003eThree main themes:\u003c/p\u003e\n\u003cp\u003e1)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; The concerned partner\u003c/p\u003e\n\u003cp\u003e2)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Inattention from partner\u003c/p\u003e\n\u003cp\u003e3)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Interaction with child\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"8\" width=\"954\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudies exploring the antenatal and postnatal period \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"35\"\u003e\n\u003cp\u003e\u003cstrong\u003e17\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eBoz, Teskereci and Akgun (2021)\u003csup\u003e32\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTurkey\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eThe experience of becoming a mother following successful IVF: a grounded theory\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eSemi-structured interviews\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(length not reported)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"181\"\u003e\n\u003cp\u003e18 mothers who had become pregnant and had a child following successful IVF\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean age \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e32 years (age range = 27-39)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarital status \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducation \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHigher education = 6 (33%)\u003c/p\u003e\n\u003cp\u003eHigh school = 2 (11%)\u003c/p\u003e\n\u003cp\u003eSecondary school = 8 (44%)\u003c/p\u003e\n\u003cp\u003eVocational school = 2 (11%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePregnancy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eMAC indication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFemale = 2 (11%)\u003c/p\u003e\n\u003cp\u003eMale = 6 (33%)\u003c/p\u003e\n\u003cp\u003eCombined = 1 (6%)\u003c/p\u003e\n\u003cp\u003eUnexplained = 9 (50%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC type\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIVF = 18 (100%)\u003c/p\u003e\n\u003cp\u003eOI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eIUI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eNot specified = 0 (0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC treatment history\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFirst attempt = 16 (89%)\u003c/p\u003e\n\u003cp\u003eTwo or more attempts = 2 (11%)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eGrounded Theory (Charmaz, 2014)\u003csup\u003e73\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"227\"\u003e\n\u003cp\u003eFour themes:\u003c/p\u003e\n\u003cp\u003e1)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Non-spontaneous path to motherhood\u003c/p\u003e\n\u003cp\u003ea)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; treatment\u003c/p\u003e\n\u003cp\u003e2)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Leaving the infertility world\u003c/p\u003e\n\u003cp\u003e3)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Pregnancy under the shadow of fear\u003c/p\u003e\n\u003cp\u003e4)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Getting stuck between fertile and infertile worlds\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"35\"\u003e\n\u003cp\u003e\u003cstrong\u003e18\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eAllan,\u0026nbsp; Mounce, Cullem Van den Akket and Hudson (2019)\u003csup\u003e27\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUK\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eTo explore non-donor IVF couples\u0026rsquo; transition to early parenthood\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eUnstructured interviews with couples\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(length approximately 40-60 minutes)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"181\"\u003e\n\u003cp\u003e16 heterosexual couples with one live singleton infant\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean age\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e(Female age range = 25-39)\u003c/p\u003e\n\u003cp\u003e(Male age range = 29-41)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePregnancy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSingle = 16 (100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eMAC indication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC type\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIVF = 16 (100%)\u003c/p\u003e\n\u003cp\u003eOI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eIUI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eNot specified = 0 (0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC treatment history\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFirst attempt = 9 (56%)\u003c/p\u003e\n\u003cp\u003eTwo or more attempts = 6 (38%)\u003c/p\u003e\n\u003cp\u003eUnknown = 1 (6%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eThematically (Frost, 2010)\u003csup\u003e74\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"227\"\u003e\n\u003cp\u003eThree themes:\u003c/p\u003e\n\u003cp\u003e1)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Preparing for parenthood\u003c/p\u003e\n\u003cp\u003e2)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Becoming a parent\u003c/p\u003e\n\u003cp\u003e3)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Considering a sibling\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"35\"\u003e\n\u003cp\u003e\u003cstrong\u003e19\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eCrespo and Bestard (2016)\u003csup\u003e26\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSpain\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eTo explore the psychosocial needs of women and their partners following assisted reproductive treatment in a Spanish Context\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eRepeated rounds of semi-structured interviews\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(Length approximately 30-90 minutes)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"181\"\u003e\n\u003cp\u003e51 participants (30 pregnant women; 21 partners)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean age\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e37 years (age range = not reported)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSpanish = 51 (100%)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMarried = 25 (83%)\u003c/p\u003e\n\u003cp\u003eSingle = 4 (13%)\u003c/p\u003e\n\u003cp\u003eDivorced = 1 (3%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHigher education = 17 (57%)\u003c/p\u003e\n\u003cp\u003eSecondary = 9 (30%)\u003c/p\u003e\n\u003cp\u003ePrimary = 4 (13%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePregnancy \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eMAC indication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFemale \u0026ndash; not reported\u003c/p\u003e\n\u003cp\u003eMale \u0026ndash; not reported\u003c/p\u003e\n\u003cp\u003eCombined \u0026ndash; not reported\u003c/p\u003e\n\u003cp\u003eUnexplained \u0026ndash; not reported\u003c/p\u003e\n\u003cp\u003eSame-sex couple = 1 (3%)\u003c/p\u003e\n\u003cp\u003eOne lone parent = 1 (3%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC type\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIVF = 26 (87%)\u003c/p\u003e\n\u003cp\u003eOI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eIUI = 4 (13%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC treatment history\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eDoes not state \u0026ndash; text was coded into either predetermined or emergent topics\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"227\"\u003e\n\u003cp\u003eTwo major themes:\u003c/p\u003e\n\u003cp\u003e1)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Complexity of reasons for anxiety\u003c/p\u003e\n\u003cp\u003e2)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Narrowing experience\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"35\"\u003e\n\u003cp\u003e\u003cstrong\u003e20\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eKatsumara, Kamiya and Emisu (2014)\u003csup\u003e31\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eJapan\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eTo clarify the experiences from pregnancy with a first child to puerperiuem and childcare, of women who became pregnant through fertility treatment.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eSemi-structured interviews\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(length approximately 29-60 minutes)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"181\"\u003e\n\u003cp\u003e9 women who received fertility treatment for a second pregnancy after giving birth to a first child through fertility treatment\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMean age\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e37 years old (range = 33-43 years old)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePregnancy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eMAC indication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFemale = 4 (44%)\u003c/p\u003e\n\u003cp\u003eMale = 1 (12%)\u003c/p\u003e\n\u003cp\u003eCombined = 0 (0%)\u003c/p\u003e\n\u003cp\u003eUnexplained = 4 (44%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC type\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIVF = 6 (67%)\u003c/p\u003e\n\u003cp\u003eOI = 0 (0%)\u003c/p\u003e\n\u003cp\u003eIUI = 2 (23%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMAC treatment history\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eContent Analysis (Greg et al., 2007)\u003csup\u003e75\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"227\"\u003e\n\u003cp\u003e17 main themes:\u003c/p\u003e\n\u003cp\u003e1)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Growing desire for a second child; contrary to expectations\u003c/p\u003e\n\u003cp\u003e2)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Lack of actual sense of pregnancy and delivery\u003c/p\u003e\n\u003cp\u003e3)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Joy and pride in pregnancy\u003c/p\u003e\n\u003cp\u003e4)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Anxiety and reassurance in selecting a birthing facility\u003c/p\u003e\n\u003cp\u003e5)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Feeling of relief at having to come this far on a long journey\u003c/p\u003e\n\u003cp\u003e6)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Acceptance that one can not have a natural delivery\u003c/p\u003e\n\u003cp\u003e7)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Fluctuation between anxiety and abnormalities or disorders in the fetus and feeling that it will be all right\u003c/p\u003e\n\u003cp\u003e8)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Thankfulness and stress with respect to family\u003c/p\u003e\n\u003cp\u003e9)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Uncertainty about continuation of pregnancy\u003c/p\u003e\n\u003cp\u003e10)\u0026nbsp; Longing for the birth of a healthy child\u003c/p\u003e\n\u003cp\u003e11)\u0026nbsp; Delivery with little sense of fulfilment\u003c/p\u003e\n\u003cp\u003e12)\u0026nbsp; Joy at becoming a mother and motivation for child rearing\u003c/p\u003e\n\u003cp\u003e13)\u0026nbsp; Joy felt from existence of baby\u003c/p\u003e\n\u003cp\u003e14)\u0026nbsp; Easing of worries regarding baby\u003c/p\u003e\n\u003cp\u003e15)\u0026nbsp; Anxiety about raising one\u0026rsquo;s first child despite joyful birth after much difficulty\u003c/p\u003e\n\u003cp\u003e16)\u0026nbsp; Weakness of one\u0026rsquo;s feelings and emotion towards birth\u003c/p\u003e\n\u003cp\u003e17)\u0026nbsp; Connection between unsettling events and medical treatment.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: IVF, In-Vitro Fertilisation; OI, Ovulation Induction; IUI, Intrauterine Insemination.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Gamete donation \u0026ndash; unknown whether this was sperm or egg donation\u003c/p\u003e\n\u003cp\u003eThe most reported demographic information was age (n=19), followed by education (n=12), marital status (n =8) and ethnicity (n=8). Participants ranged from 24 to 53 years in age and were commonly educated to degree level (see Table 2).\u0026nbsp; Various MAC methods were recorded across studies, including IVF (n = 18), ICSI (n=7) and the use of donor gametes (n=6). Eleven studies had mixed samples of MAC and other less invasive forms of treatment, such as IUI or OI.\u003c/p\u003e\n\u003cp\u003eMost studies (n=17) recruited individuals with a history of infertility; only one study recruited a mixed sample including a same-sex couple and a lone parent\u003csup\u003e26\u003c/sup\u003e. Three studies did not report the reason for MAC\u003csup\u003e10, 27, 28\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eAll studies collected data via interview, ranging in length from 29 to 180 minutes. The qualitative methodology most frequently employed was Interpretative Phenomenology (n=7) followed by, Content Analysis (n=6) Thematic Analysis (n=3), Grounded Theory (n=1) and Modified Analytic Induction (n=1).\u0026nbsp; Two studies did not specify their method\u003csup\u003e26, 29\u003c/sup\u003e.\u003c/p\u003e\n\u003ch3\u003eQuality appraisal and risk of bias of studies\u003c/h3\u003e\n\u003cp\u003eMethodological quality varied across studies, as can be seen in Table 3. Agreement between raters was (94%, k = 0.765, p\u0026lt;.001, rated as \u0026lsquo;substantial agreement\u0026rsquo;). Most studies were rated as \u0026lsquo;moderate\u0026rsquo; quality (n=13), followed by high (n=5). Two studies\u003csup\u003e30,31\u003c/sup\u003e were rated low in quality. No studies sufficiently referenced reflexivity, a fundamental process to qualitative research; this was a general weakness of all studies.\u003c/p\u003e\n\u003cp\u003eTable 3: Overview of the methodological quality appraisal of the 20 included studies\u003c/p\u003e\n\u003ctable width=\"926\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"36\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003e\u003cstrong\u003eStudy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAims\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e\u003cstrong\u003eRecruitment\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e\u003cstrong\u003eReflexivity\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003e\u003cstrong\u003eEthical issues\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003e\u003cstrong\u003eStatement of findings\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003e\u003cstrong\u003eValuable\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e\u003cstrong\u003eScore and overall rating (0-10)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003eDornelles et al. (2016)\u003csup\u003e35\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e\u003cstrong\u003eModerate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(7)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003eSonego et al. (2017)\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e\u003cstrong\u003eModerate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(6)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003eWalker et al. (2017)\u003csup\u003e10\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e\u003cstrong\u003eModerate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(7)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003eWarmelink et al. (2016)\u003csup\u003e40\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e\u003cstrong\u003eModerate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(7)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003eFrench et al. (2015)\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e\u003cstrong\u003eHigh\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(8)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003eRanjbar et al. (2015)\u003csup\u003e9\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e\u003cstrong\u003eModerate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(7)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003eDornelles et al. (2014)\u003csup\u003e33\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e\u003cstrong\u003eModerate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(6)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003eLin et al. (2013)\u003csup\u003e34\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e\u003cstrong\u003eHigh\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(8.5)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003eSmorti and Smorti (2013)\u003csup\u003e29\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e\u003cstrong\u003eModerate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(7.5)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003eDornelles and Lopes (2011)\u003csup\u003e30\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e\u003cstrong\u003eLow\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(4.5)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003eSilva and Lopes (2011)\u003csup\u003e37\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e\u003cstrong\u003eModerate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(6)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003eHayashi and Sayama (2009)\u003csup\u003e11\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e\u003cstrong\u003eModerate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(7.5)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36\"\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003eD\u0026iacute;az S\u0026aacute;ez et al. (2021)\u003csup\u003e28\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e\u003cstrong\u003eModerate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(7)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003eSadeghi et al. (2019)\u003csup\u003e39\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e\u003cstrong\u003eModerate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(7.5)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003eMohammadi et al. (2015)\u003csup\u003e36\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e\u003cstrong\u003eHigh\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(8.5)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003eBracks-Zalloua et al. (2011)\u003csup\u003e38\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e\u003cstrong\u003eHigh\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(8)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36\"\u003e\n\u003cp\u003e17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003eBoz et al. (2021)\u003csup\u003e32\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e\u003cstrong\u003eHigh\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(9)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003eAllan et al. (2019)\u003csup\u003e27\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e\u003cstrong\u003eModerate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(7)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36\"\u003e\n\u003cp\u003e19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003eCrespo and Bestard (2016)\u003csup\u003e26\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e\u003cstrong\u003eModerate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(7)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ee\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003eKatsumara et al. (2014)\u003csup\u003e31\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003cp\u003e(1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003e(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003eC T\u003c/p\u003e\n\u003cp\u003e(0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e\u003cstrong\u003eLow\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(4.5)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003e% of included studies rated as \u0026lsquo;Yes\u0026rsquo;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e50%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e35%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e60%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003e55%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003e35%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003e90%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"59\"\u003e\n\u003cp\u003e80%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAbbreviation: CT, Can\u0026rsquo;t Tell\u003cstrong\u003e.\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003eFindings\u003c/h3\u003e\n\u003cp\u003eThree main themes and seven subthemes were identified (Figure 2) which will be illustrated through selected quotes. A matrix of themes (see Appendix 2) illustrates which themes were present for each study.\u003c/p\u003e\n\u003ch3\u003eTheme 1: The vulnerable parent: fear, doubt and uncertainty\u003c/h3\u003e\n\u003cp\u003eThis theme, consisting of two subthemes, encompasses the uncertainty, doubt and fear individuals experienced as they entered pregnancy, lacking a sense of safety. Commonly, this lack of safety was expressed in hypervigilance, fears of pregnancy loss and fetal abnormalities, with parents living cautiously, seeking reassurance and acting to protect their child during pregnancy and parenting.\u003c/p\u003e\n\u003ch3\u003eSubtheme 1.1: Lacking a sense of safety\u003c/h3\u003e\n\u003cp\u003ePregnancy was an emotionally overwhelming time for expectant parents. Ambivalence often accompanied successful conception with paradoxical feelings reported\u003csup\u003e9, 26, 31, 32\u003c/sup\u003e\u0026nbsp; For some, it was described as \u0026ldquo;the end of a nightmare\u0026rdquo;\u003csup\u003e29 (p.171)\u003c/sup\u003e, feeling victorious that their \u0026ldquo;fight\u0026rdquo;\u003csup\u003e29 (p.171)\u003c/sup\u003e with fertility or MAC was over. Others attempted to limit their excitement, as a form of self-protection: \u003cem\u003e\u0026ldquo;I think to a certain extent until he almost turned up, there was part of me that was just like, I guess having gone through the whole IVF thing, I was just like, I just don\u0026rsquo;t want to get too excited\u0026hellip;\u0026rdquo;\u003c/em\u003e\u003csup\u003e27 (p.25)\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eDoubt and disbelief regarding the pregnancy were expressed\u003csup\u003e9, 12, 32-34, \u003c/sup\u003e\u0026nbsp;linked to previous failed attempts to conceive\u003csup\u003e31, 34, 35 \u003c/sup\u003e. Intense states of worry quickly followed with fears regarding the viability of the pregnancy and miscarriage prominent\u003csup\u003e11, 12, 27, 29-35 \u003c/sup\u003e, particularly during the first trimester.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe MAC journey influenced reactions to pregnancy: \u0026ldquo;\u003cem\u003eIt\u0026rsquo;s taken so long to get here, that it\u0026rsquo;s not the same, or maybe it is, we don\u0026rsquo;t know; but a woman who gets pregnant naturally or has no trouble getting pregnant may not think about things as much as someone who\u0026rsquo;s spent two years going through this process\u003c/em\u003e\u0026rdquo; \u003csup\u003e26 (p.95)\u003c/sup\u003e\u003cem\u003e. \u003c/em\u003eThese reactions led to significant value being placed on the pregnancy\u003csup\u003e14,35\u003c/sup\u003e with difficulties in imagining a future life with their baby: \u0026ldquo;\u003cem\u003eI always feared that something would happen to my child. As if taking it in my arms was impossible\u0026hellip;\u003c/em\u003e\u0026rdquo;\u003csup\u003e32 (p. 4177)\u003c/sup\u003e. For some, these fears diminished at significant milestones\u003csup\u003e12,29\u003c/sup\u003e, with a growing sense of stability as the pregnancy progressed\u003csup\u003e34\u003c/sup\u003e. However, for others, these worries persisted throughout, switching to fears of stillbirth\u003csup\u003e30,31,33\u003c/sup\u003e. In papers that discussed the non-gestating partners\u0026rsquo; perspectives (in this case, all male partners\u0026rsquo; perspectives) these fears were often less apparent\u003csup\u003e12,14,29\u003c/sup\u003e, reassured by their partners\u0026rsquo; changing bodies.\u003c/p\u003e\n\u003cp\u003eIndividuals lacked trust in their own bodies\u003csup\u003e11,12\u003c/sup\u003e and feared they could not sustain the pregnancy\u003cem\u003e: \u0026ldquo;\u0026hellip;t\u003c/em\u003e\u003cem\u003eo be honest I just stopped trusting my body, it never behaves at it should do, if you expect it to do something, it will do something else\u0026rdquo;\u003c/em\u003e\u003csup\u003e12 (p.573)\u003c/sup\u003e\u003cem\u003e. \u003c/em\u003eThese fears often became an obstacle to live the pregnancy fully, impacted bonding: \u0026ldquo;\u003cem\u003eNow I am in doubt whether I should bond with her. What if something happens to that or a problem occurs\u0026rdquo; \u003c/em\u003e\u003csup\u003e9 (p.5)\u003c/sup\u003e. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants were reluctant to disclose or were eager to minimise the physical and psychological burdens of pregnancy and the impact of MAC treatment\u003csup\u003e,35\u003c/sup\u003e, due to their long desire to be parents. For some, pregnancy was viewed as a \u0026ldquo;reward\u0026rdquo; that \u0026ldquo;compensated\u0026rdquo;\u003csup\u003e35 (p.125)\u003c/sup\u003e for the challenges they had encountered. However, studies published in the UK reported a reduced entitlement to complain about the challenges of pregnancy and parenting\u003csup\u003e12,27\u003c/sup\u003e, reflecting potential cultural differences.\u003c/p\u003e\n\u003cp\u003eThe health of the baby was a dominant theme across studies. Concerns regarding fetal abnormality\u003csup\u003e11,30,31,33,34\u003c/sup\u003e, prematurity\u003csup\u003e11,31,34\u003c/sup\u003e and disability\u003csup\u003e11\u003c/sup\u003e were found. These feelings were heightened before or during prenatal visits\u003csup\u003e35\u003c/sup\u003e and often persisted throughout pregnancy\u003csup\u003e33\u003c/sup\u003e. For some, the fear of abnormalities and disabilities disappeared upon greeting their baby\u003csup\u003e31\u003c/sup\u003e, whereas for other parents this persisted into the parenting journey, considering their child more vulnerable to illness and injury\u003csup\u003e36\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eSubtheme 1.2: Acting to protect\u003c/h3\u003e\n\u003cp\u003eThe uncertainty, anxiety and fear associated with pregnancy often led to hypervigilance, and monitoring of bodily symptoms\u003csup\u003e9, 11, 14, 27, 34, 36,\u003c/sup\u003e,with any indication of difficulty destabilising individuals, causing emotional turmoil:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I always checked my underwear in bathroom to see if there is any problem. Two weeks ago it seemed that I had some brownish spots. It was the time when I just sat and started crying loudly\u0026rdquo;\u003c/em\u003e\u003csup\u003e9 (p.5)\u003c/sup\u003e. On noticing any physiological changes, individuals swiftly sought the help of health professionals. For expectant fathers, this anxiety was expressed through constant checking and monitoring of their partner: \u003cem\u003e\u0026ldquo;Every time (mother) left the room I was like \u0026lsquo;you alright, alright?\u0026rsquo; Every time, I was like \u0026lsquo;is everything alright\u0026rdquo;\u003c/em\u003e\u003csup\u003e27 (p.439)\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eA need for reassurance was evident leading individuals to repeatedly perform pregnancy tests\u003csup\u003e12,26,27,32\u003c/sup\u003e and seek medical help\u003csup\u003e11,34\u003c/sup\u003e\u003cem\u003e: \u0026ldquo;After I learned that I was pregnant, I kept repeating the urine pregnancy tests every day. I was so afraid that the baby was not inside\u003c/em\u003e\u0026rdquo;\u003csup\u003e32 (p.4177)\u003c/sup\u003e. Changes in body shape and fetal movement helped individuals fully realise and believe in their pregnancy\u003csup\u003e32\u003c/sup\u003e, increasing their sense of responsibility and feelings of protection\u003csup\u003e11\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eMAC added to the fragility of pregnancy: \u003cem\u003e\u0026ldquo;Because he was IVF you kind of think, because he didn\u0026rsquo;t happen naturally, you\u0026rsquo;re extra careful and extra cautious because it was like, it is your one shot\u0026rdquo;\u003c/em\u003e\u003csup\u003e27 (p.439)\u003c/sup\u003e. Both parents reported a growing sense of responsibility\u003csup\u003e9,14,29\u003c/sup\u003e, with the developing baby prioritised: \u0026ldquo;\u003cem\u003eI took a LOA for one year and rested in bed for a long time. There was only one focus in my life at the time, the babies inside me. I knew that only I was able to protect the two babies in my belly. I had to guard them with my life\u003c/em\u003e\u0026rdquo;\u003csup\u003e34 (p.4)\u003c/sup\u003e. This responsibility led to acts of protection and modification of lifestyle such as delaying or reducing physical activity\u003csup\u003e9,10,30,32,34\u003c/sup\u003e, working patterns\u003csup\u003e11,34\u003c/sup\u003e, sexual intercourse\u003csup\u003e9,37\u003c/sup\u003e and changes to diet \u003csup\u003e10,34\u003c/sup\u003e. This sense of caution resulted in delayed preparations\u003csup\u003e11,12\u003c/sup\u003e, including arranging the nursery or buying items\u003cem\u003e: \u0026ldquo;You know, people keep saying, \u0026lsquo;Have you decorated the nursery?\u0026rsquo; and I can\u0026rsquo;t think of anything worse than coming home to a decorated nursery, you know, if, if things go wrong you know\u003c/em\u003e\u0026rdquo;\u003csup\u003e12 (p.173)\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eExpectant fathers reported feeling protective of their pregnant partner, \u0026ldquo;\u003cem\u003etaking care\u003c/em\u003e\u0026rdquo; of them\u003csup\u003e14 (p.4)\u003c/sup\u003e, by attending appointments, providing emotional and financial support\u003csup\u003e14\u003c/sup\u003e. These feelings of protection persisted into the parental journey\u003csup\u003e32,36\u003c/sup\u003e, with parents attempting to safeguard their infant from harm.\u003c/p\u003e\n\u003ch3\u003eTheme 2: The stark realisation of the parental dream\u003c/h3\u003e\n\u003cp\u003eThe journey to parenthood often starkly contrasted to individuals\u0026rsquo; hopes and expectations. For some, the process of becoming a parent was embraced, whereas others struggled to realise their dream. This theme, with its three subthemes, encapsulates individuals\u0026rsquo; transition of identity, approaches to parenting and their onward journey, considering future family formation.\u003c/p\u003e\n\u003ch3\u003eSubtheme 2.1: Navigating old and new identities\u003c/h3\u003e\n\u003cp\u003eThe transition in identity began at the point of conception for some\u003csup\u003e11\u003c/sup\u003e. However, for others this was a complicated process with a \u0026ldquo;\u003cem\u003efragile, obscure and unstable\u003c/em\u003e\u0026rdquo; identity\u003csup\u003e34 (p.5)\u003c/sup\u003e, particularly during the first trimester. Achieving pregnancy did not erase individuals\u0026rsquo; conception journey, impacting their ability to embrace their newly emerging identity\u003csup\u003e10,30,32,34\u003c/sup\u003e , causing disturbances in the self: \u003cem\u003e\"it may come to something positive [changes brought about by maternity], maybe not, ... I lost my personality, my identity... . Who am I?\"\u0026nbsp;\u003c/em\u003e\u003csup\u003e33 (p.494)\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eCouples\u0026rsquo; views on MAC impacted their ability to accept their new identity expressing concerns about their ability to care for their baby\u003csup\u003e33\u003c/sup\u003e. Some minimised\u003csup\u003e11,35,38\u003c/sup\u003e and \u0026ldquo;\u003cem\u003erejected\u0026rdquo;\u003c/em\u003e\u003csup\u003e27 (p.441)\u003c/sup\u003e their previous infertility and the impact of MAC, whereas others demonstrated acceptance\u003csup\u003e11,26\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe birth was a significant moment in the transition of identity. For some, there was a strong desire to birth naturally with feelings of disappointment and regret at requiring medical intervention\u003csup\u003e31\u003c/sup\u003e. Following the birth, feelings of \u0026ldquo;\u003cem\u003eshock\u003c/em\u003e\u0026rdquo; \u003csup\u003e26 (p.70)\u003c/sup\u003e were reported. For many, physically seeing or holding their infant was necessary to realise their parental identity and joy\u003csup\u003e11,14\u003c/sup\u003e: \u003cem\u003e\"I want to do my best to raise my baby by seeing and touching my baby and realizing that I have become a mother\"\u003c/em\u003e\u003csup\u003e31 (p.225)\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eFeeling \u0026ldquo;\u003cem\u003ecomplete\u003c/em\u003e\u0026rdquo;\u003csup\u003e34 (p.6)\u003c/sup\u003e upon their baby\u0026rsquo;s arrival and viewing their parenting role as \u0026ldquo;\u003cem\u003eamazing\u003c/em\u003e\u0026rdquo;, or \u0026ldquo;\u003cem\u003eincredible\u003c/em\u003e\u0026rdquo;\u003csup\u003e27 (p.440)\u003c/sup\u003e were reported: \u0026ldquo;\u003cem\u003eThe joy of having a baby is much greater than winning a lottery . . . I think that is the greatest happiness in my life. This is something I could never have realised before I became a Mum\u003c/em\u003e\u0026rdquo;\u003csup\u003e34 (p.6)\u003c/sup\u003e. However, the lasting impact of MAC was evident for parents, fading into the background, yet etched in their minds: \u0026ldquo;\u003cem\u003eAnd I remember feeling that I wouldn\u0026rsquo;t ever forget how hard that actually was to go through the treatment and I don\u0026rsquo;t think I have to some extent, but I feel like it\u0026rsquo;s faded a bit into the background\u0026rdquo;\u003c/em\u003e\u003csup\u003e27 (p.442)\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003ePregnancy and motherhood were considered fundamental to being a woman: \u003cem\u003e\u0026ldquo;becoming a mother really meant feeling like a woman\u0026rdquo;\u003c/em\u003e\u003csup\u003e32(p.4179)\u003c/sup\u003e. Individuals reported feeling more valued because of their pregnancy, increasing self-confidence, reclaiming their sense of self\u003csup\u003e9,11,30 \u003c/sup\u003eand restoring trust in their bodies\u0026rsquo; capability\u003csup\u003e11,32\u003c/sup\u003e.\u003c/p\u003e\n\u003ch3\u003eSubtheme 2.2: The need to be a perfect parent, for their precious baby\u003c/h3\u003e\n\u003cp\u003eThe pregnancy and baby were often viewed as \u0026ldquo;\u003cem\u003eprecious\u003c/em\u003e\u0026rdquo;\u003csup\u003e27 (p.442) ,32 (p.4179)\u003c/sup\u003e, \u0026ldquo;\u003cem\u003edelicate\u003c/em\u003e\u0026rdquo;\u003csup\u003e33 (p.118)\u003c/sup\u003e, \u0026ldquo;\u003cem\u003especial\u003c/em\u003e\u0026rdquo;\u003csup\u003e35 (p.126)\u003c/sup\u003e or \u0026ldquo;\u003cem\u003ehighly valued\u003c/em\u003e\u0026rdquo;\u003csup\u003e38 (p.2)\u003c/sup\u003e, impacting approaches to parenting. This presented with parents needing to provide \u0026ldquo;\u003cem\u003eperfect\u003c/em\u003e\u0026rdquo; care\u003csup\u003e32 (p.4179), 36, (p.48)\u003c/sup\u003e, centring their lives around the infant, with parental needs secondary\u003csup\u003e32,38,39\u003c/sup\u003e. This parental approach sometimes led to more permissive parenting styles, fulfilling the child\u0026rsquo;s every wish and a reluctance to provide consequences: \u003cem\u003e\u0026ldquo;We would do everything she wanted\u003c/em\u003e\u0026rdquo;\u003csup\u003e39 (p.1791)\u003c/sup\u003e. Not only was the child viewed as highly \u0026ldquo;special\u0026rdquo;, but the mother also: \u003cem\u003e\u0026ldquo;We are not better mothers, but more special. When you want something so much, you appreciate it and take care of it with more care. I worry a little more about him because he was so longed for\u0026rdquo;\u003c/em\u003e\u003csup\u003e28 (p.72)\u003c/sup\u003e. Gratitude was expressed by parents\u003csup\u003e27\u003c/sup\u003e, acknowledging that their experience of MAC changed their \u0026ldquo;\u003cem\u003eperspectives\u003c/em\u003e\u0026rdquo;\u003csup\u003e27 (p.441)\u003c/sup\u003e and tempered the challenges parenthood brings, helping parents to maintain a sense of \u0026ldquo;\u003cem\u003ecalm\u003c/em\u003e\u0026rdquo;\u003csup\u003e27 (p.441)\u003c/sup\u003e in stressful situations.\u003c/p\u003e\n\u003cp\u003eThe fears of loss apparent in pregnancy overspill into parenting\u003csup\u003e39\u003c/sup\u003e, leading to concern, \u0026ldquo;\u003cem\u003eover-protection\u003c/em\u003e\u0026rdquo;\u003csup\u003e36 (p.48)\u003c/sup\u003e and over-involved parenting\u003csup\u003e32,36,39\u003c/sup\u003e. This was characterised by constant monitoring\u003csup\u003e33,36,39\u003c/sup\u003e and supervision of their infants: \u003cem\u003e\u0026ldquo;I\u0026rsquo;m very careful, I\u0026rsquo;m afraid that something bad happens for him, always keep an eye on him and keep him with me\u0026rdquo;\u003c/em\u003e\u003csup\u003e39 (p.1791)\u003c/sup\u003e. Mohammadi et al. (2015)\u003csup\u003e36\u003c/sup\u003e reported an \u0026ldquo;\u003cem\u003eover-emotional investment\u003c/em\u003e\u0026rdquo; characterised by enmeshment of mother and infant\u003cem\u003e: \u0026ldquo;He saved my life. Every second I think about him, I\u0026rsquo;m totally obsessed with his future\u003c/em\u003e\u003csup\u003e36 (p.48)\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eDifferent approaches to parenthood were noted between male and female partners\u003csup\u003e38\u003c/sup\u003e, with fathers referenced as more \u0026ldquo;\u003cem\u003elaid back\u003c/em\u003e\u0026rdquo;, \u0026ldquo;\u003cem\u003eplayful\u003c/em\u003e\u0026rdquo; and less protective\u003csup\u003e38 (p.7)\u003c/sup\u003e\u003cem\u003e. \u003c/em\u003eContrary to this, Allan et al. (2019)\u003csup\u003e27\u003c/sup\u003e reported the unification of parents in their approach to parenthood, with close involvement and negotiation from both parents.\u003c/p\u003e\n\u003cp\u003eStrong desires to breastfeed were reported\u003csup\u003e28,31,\u003c/sup\u003e, with mothers wanting to offer their child the \u003cem\u003e\u0026ldquo;best start\u0026rdquo;\u003c/em\u003e\u003csup\u003e28 (p.70)\u003c/sup\u003e. Often individuals endured physical pain and self-sacrifice to continue with their quest to breastfeed\u003cem\u003e: \u0026ldquo;The cracks hurt a lot, when I had been breastfeeding for a little, the pain went down a little bit, but I thought about stopping breastfeeding. I made the sacrifice and put up with the pain for him, and I don\u0026rsquo;t regret it\u0026rdquo;\u003c/em\u003e\u003csup\u003e28 (p.71)\u003c/sup\u003e. Opposingly, prolonged breastfeeding was evident\u003csup\u003e28,38\u003c/sup\u003e, linked to feelings of protection and bonding.\u003c/p\u003e\n\u003ch3\u003eSubtheme 2.3: The onward journey\u003c/h3\u003e\n\u003cp\u003eThoughts and feelings regarding future family formation and the decision to have another child were discussed\u003csup\u003e26,27,32,39\u003c/sup\u003e. Having another child was not viewed as a guarantee\u003csup\u003e39\u003c/sup\u003e, with many fearful of re-embarking on the MAC journey\u003csup\u003e32,39\u003c/sup\u003e, reminded of the emotional turmoil\u003csup\u003e27\u003c/sup\u003e, pain\u003csup\u003e27, 32 (p.4177)\u003c/sup\u003e and anxiety\u003csup\u003e32\u003c/sup\u003e previously experienced. Attachment to frozen embryos were reported\u003csup\u003e27\u003c/sup\u003e and comments from others regarding a second child were hurtful reminders of their journey to conception\u003csup\u003e27\u003c/sup\u003e.\u003c/p\u003e\n\u003ch3\u003eTheme 3: Psychosocial needs and support\u003c/h3\u003e\n\u003cp\u003eThis theme and its two subthemes captured individuals\u0026rsquo; psychosocial care needs as they navigated complex health systems, relationships within their own support networks and the impact of sociocultural context.\u003c/p\u003e\n\u003ch3\u003eSubtheme 3.1: Unmet care needs\u003c/h3\u003e\n\u003cp\u003eWhilst the desire to receive routine antenatal care\u003csup\u003e39\u003c/sup\u003e and to be treated \u003cem\u003e\u0026ldquo;like everyone else\u0026rdquo;\u003c/em\u003e\u003csup\u003e12 (p.574)\u003c/sup\u003e were presented, the care needs of some individuals contradicted this\u003csup\u003e12,39\u003c/sup\u003e. Discharge from the fertility centre brought satisfaction, signalling the end of their MAC journey\u003csup\u003e40\u003c/sup\u003e. However, ambivalence regarding the transition was evident, with \u0026ldquo;\u003cem\u003egaps in care\u003c/em\u003e\u0026rdquo; reported\u003csup\u003e12 (p.574)\u003c/sup\u003e. This was often an anxious time for individuals lacking in containment: \u003cem\u003e\u0026ldquo;We didn\u0026rsquo;t really know who to turn to, we hadn\u0026rsquo;t seen our midwife yet and we needed to know everything was okay with the pregnancy, so we paid for a private dating scan\u003c/em\u003e\u0026rdquo;\u003csup\u003e12 (p.574)\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eParticipants\u0026rsquo; care needs were not adequately addressed by routine services, with little understanding or attention from health professionals regarding their conception journey\u003csup\u003e12,40\u003c/sup\u003e. Increased care needs\u003csup\u003e40\u003c/sup\u003e were reported, requiring additional appointments and scans to contain their anxiety. There were barriers to discussing their concerns with health professionals in fear of being perceived as \u0026ldquo;\u003cem\u003eungrateful\u003c/em\u003e\u0026rdquo;\u003csup\u003e12 (p.105)\u003c/sup\u003e, often requiring prompts from professionals to initiate discussions\u003csup\u003e40\u003c/sup\u003e. Nevertheless, certain qualities were valued in health professionals, such as knowledge regarding their conception journey, personalised care, clear and consistent communication, more frequent appointments, understanding and reassurance\u003csup\u003e10,12,40\u003c/sup\u003e.\u003c/p\u003e\n\u003ch3\u003eSubtheme 3.2: The journey from exclusion and marginalisation to acceptance and belonging\u003c/h3\u003e\n\u003cp\u003eFeelings of difference were experienced in pregnancy after MAC\u003csup\u003e9,11,12,27,32\u003c/sup\u003e. \u0026ldquo;\u003cem\u003eResentment\u003c/em\u003e\u0026rdquo;\u003csup\u003e27 (p.441)\u003c/sup\u003e towards spontaneously conceiving couples was expressed, feeling others could not understand their journey to conception\u003csup\u003e12,32\u003c/sup\u003e, or the emotions that pregnancy brings\u003csup\u003e32\u003c/sup\u003e. The uncertainty associated with pregnancy often translated into reluctance to share their pregnancy news with others\u003csup\u003e9,11,26,29,34\u003c/sup\u003e: \u0026ldquo;\u003cem\u003eonly tell immediate family and friends and then if it hasn\u0026rsquo;t worked, we can then be open and honest again, once we\u0026rsquo;ve kind of healed a bit\u0026rdquo;\u003c/em\u003e\u003csup\u003e10 (p.370)\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eAchieving pregnancy brought complex emotional reactions and a sense of betrayal to their previous childless identity\u003csup\u003e9,12\u003c/sup\u003e. Reports of guilt, empathy and sadness for those still trying to achieve pregnancy were commented upon\u003csup\u003e9,11\u003c/sup\u003e.\u0026nbsp; Parents reported \u0026ldquo;\u003cem\u003efinding meaning in life\u003c/em\u003e\u0026rdquo;\u003csup\u003e9 (p.4)\u003c/sup\u003e once pregnancy was achieved, shifting from a position of isolation to connection, feeling supported by others such as health professionals, family and friends\u003csup\u003e9,32\u003c/sup\u003e, bringing hope and optimism\u003csup\u003e9\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eGoing through MAC and achieving pregnancy was reported to strengthen marital relationships\u003csup\u003e9,26,30,37\u003c/sup\u003e with the partner reported as the biggest source of support during pregnancy\u003csup\u003e34\u003c/sup\u003e. A reduction in conflict, improved communication and understanding were noted\u003csup\u003e37\u003c/sup\u003e. Furthermore, having a biological child led to greater feelings of acceptance and connection with the partner\u0026rsquo;s family: \u0026ldquo;\u003cem\u003eI was finally connected with my husband\u0026rsquo;s family after having the baby, and the baby represented a biological link. Otherwise, I would have always been an outsider\u0026rdquo;\u003c/em\u003e\u003csup\u003e37 (p.6)\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eAs the pregnancy progressed, individuals relied on family and close friends\u003csup\u003e27\u003c/sup\u003e to provide practical and emotional support, both antenatally and postnatally\u003csup\u003e9,28,30,34\u003c/sup\u003e. Furthermore, making new connections with others who had conceived via MAC was a welcomed bonding experience\u003csup\u003e27\u003c/sup\u003e facilitated by internet forums\u003csup\u003e10\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSociocultural norms regarding conception influenced individuals\u0026rsquo; ability to integrate their former and current selves\u003csup\u003e27\u003c/sup\u003e. Having a child seemed to hold cultural significance, with the impact of society particularly evident in papers conducted in Asia. In some instances, individuals never disclosed their use of MAC in achieving pregnancy due to fears of shame and negativity from their community\u003csup\u003e9,39\u003c/sup\u003e.\u0026nbsp; Individuals felt free from stigmatisation on achieving pregnancy\u003csup\u003e9\u003c/sup\u003e, feeling more accepted by others and society, increasing self-worth: \u003cem\u003e\u0026ldquo;In every party or religious ceremony people came to me and said we bring this for you because of your pregnancy. The feeling and opinion of people toward me has changed now\u003c/em\u003e\u0026rdquo;\u003csup\u003e9 (p.4)\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe role of religion and spirituality was reflected upon\u003csup\u003e9,34,36, 39\u003c/sup\u003e, helping individuals manage and cope with the uncertainty and doubt that accompanied pregnancy: \u003cem\u003e\u0026ldquo;Sometimes I feel that I can do nothing more myself. I read holy Quran and say prayers. I rely on the strength from God\u0026rdquo;\u003c/em\u003e\u003csup\u003e9 (p.6)\u003c/sup\u003e.\u003cem\u003e\u0026nbsp; \u003c/em\u003eParents prayed for a successful pregnancy\u003csup\u003e9,34\u003c/sup\u003e and, in some instances, attributed the birth to God\u003csup\u003e36\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study achieved its aim of exploring the experiences of pregnancy and early parenting in individuals who conceived via MAC, identifying their psychological, social and health care needs. This is the first review to qualitatively synthesise the antenatal and parenting experiences of both parents who conceive via MAC.\u0026nbsp; Overall, achieving pregnancy brought complex emotional reactions and lacked in a sense of safety, with amplified care needs identified. The health and survival of the baby preoccupied parents\u0026rsquo; thoughts, leading to acts of protection and cautious living, impacting their transition to parenthood and their identity as a parent. This transition to parenthood can be a lengthy, non-linear process, influenced by health systems and the sociocultural context.\u003c/p\u003e\n\u003cp\u003eThis review confirmed that pregnancy following MAC was associated with pregnancy-specific anxiety, fears of pregnancy loss and concerns regarding the health of the baby\u003csup\u003e5,7,8\u003c/sup\u003e. This heightened state of threat impacts parents\u0026rsquo; ability to imagine a life with their baby and, in some cases, impacts bonding. This is significant, given maternal representations during pregnancy are predictors of attachment one year postnatally\u003csup\u003e41\u003c/sup\u003e. Furthermore, pregnancy is a critical time for the neurodevelopment of the developing baby. According to the \u0026lsquo;fetal origins hypothesis\u0026rsquo; the utero environment can have a sustained impact across the lifespan\u003csup\u003e42\u003c/sup\u003e. Prenatal maternal anxiety can impact the neurobehavioural development of the fetus\u003csup\u003e43-45\u003c/sup\u003e, with long-term effects observed on the child\u0026rsquo;s cognitive ability\u003csup\u003e45,46\u003c/sup\u003e and emotional adjustment\u003csup\u003e47\u003c/sup\u003e. The findings from this review may have implications for clinical guidance, suggesting a need for early identification and monitoring of psychological distress, with targeted interventions to reduce pregnancy-specific anxiety. These findings hint at the potential value in identifying pregnancy following MAC as a risk factor for emotional vulnerability, which may need to be considered for any future revisions to antenatal and postnatal guidance. However, more studies in this area are required to further support and substantiate this recommendation.\u003c/p\u003e\n\u003cp\u003ePerceived social stigma impacted parents\u0026rsquo; relationship to help.\u0026nbsp; Hammarberg et al.\u0026rsquo;s\u0026nbsp; mixed methods review\u003csup\u003e5 \u003c/sup\u003esuggested individuals might \u0026ldquo;idealise\u0026rdquo;\u003csup\u003e5(p.411)\u003c/sup\u003e parenthood with a reduced sense of entitlement to complain the about the negative aspects of parenting. This review identified this notion both antenatally and postnatally. French et al.\u003csup\u003e12 \u0026nbsp;\u003c/sup\u003ereferred to this as \u0026ldquo;self-silencing\u0026rdquo;\u003csup\u003e12 (p.574)\u003c/sup\u003e. Self-silencing or the internalisation of difficulties has been linked to depression\u003csup\u003e48-50\u003c/sup\u003e, lower levels of self-esteem and disturbances in identity\u003csup\u003e51\u003c/sup\u003e. This finding is important given the potential negative consequences for maternal mental-health and the mother-baby relationship\u003csup\u003e52\u003c/sup\u003e.\u0026nbsp; Normalising parental experiences and reducing stigma and shame regarding MAC are important milestones for health services and society to achieve.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe transition to parenthood was often complex for expectant parents, facing unique challenges.\u0026nbsp; Maehara et al. (2021)\u003csup\u003e8\u003c/sup\u003e made similar observations in their review, suggesting the acquisition of the maternal identity was delayed, defending against any anticipated disappointments and loss. Individual variability regarding the transition of identity was noted across studies. For some, the transition in identity began at the point of conception\u003csup\u003e11\u003c/sup\u003e, whereas others struggled to realign their old and new identities, needing to physically see and hold their infant to realise their dream of having a baby. Shifts in identity have been linked to anxiety and confusion\u003csup\u003e53\u003c/sup\u003e, making this an important issue to identify, assess and support with.\u003c/p\u003e\n\u003cp\u003eThis review identified the significant role of culture and society in shaping experiences of pregnancy and parenting following MAC. Individual, familial and cultural values, regarding reproduction and gender, impact acceptance of MAC and the transition of identity. The sociocultural context featured heavily in papers written in countries with collectivist cultures, amid societal pressures regarding child-rearing\u003csup\u003e34,36,39\u003c/sup\u003e. Parents felt ostracised by their previous childless identity and stigmatised for their use of MAC, impacting help-seeking from services and their own support networks. Greater acknowledgement of the sociocultural factors impacting expectant parents are necessary within health services.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis meta-synthesis was novel as it qualitatively synthesised the experiences of both parents following MAC. Four of the included papers reviewed the experiences of couples and two focused specifically on the male partner\u0026rsquo;s experience. The reviewed literature suggested fears of pregnancy loss were less apparent in male partners. However, there was indication of anxiety and hypervigilance was expressed through checking and monitoring the health status of their partner\u003csup\u003e27\u003c/sup\u003e. A sense of growing responsibility was reported for both parents; with male partners expressing this via acts of protection towards the gestating partner antenatally. This suggests a potential need for health services to monitor the emotional well-being of both parents following MAC.\u0026nbsp;\u0026nbsp; From the studies that explored the father\u0026rsquo;s perspective, there were suggested differences in the approaches to parenting across parental couples, with the males self-identifying as more \u0026lsquo;relaxed\u0026rsquo; and \u0026lsquo;playful\u0026rsquo;.\u003c/p\u003e\n\u003cp\u003eThis meta-synthesis enhanced and extended the findings of Maehara et al.\u003csup\u003e8\u003c/sup\u003e, identifying that individuals\u0026rsquo; conception journey persisted into parenthood, leading to acts of protection. These acts of protection may be individuals\u0026rsquo; attempts to reclaim an internal locus of control\u003csup\u003e54\u003c/sup\u003e to combat the uncertainty and loss of control during MAC and pregnancy. Quantitative studies have reported varied responses in adjustments to parenting\u003csup\u003e5\u003c/sup\u003e, with a suggestion of no differences compared to spontaneously conceiving mothers\u003csup\u003e55\u003c/sup\u003e. However, the reviewed qualitative literature suggests a need to provide idealised and \u0026ldquo;\u003cem\u003eperfect care\u003c/em\u003e\u0026rdquo;\u003csup\u003e32,36\u003c/sup\u003e with high levels of psychological investment in their child. According to Meighan\u0026rsquo;s Becoming a Mother Theory\u003csup\u003e56\u003c/sup\u003e, parents or mothers mostly are required to establish responsibilities and boundaries for themselves and their baby.\u0026nbsp; Failure to integrate and process their conception journey may impact this process, leading to over-involved, over-protective, permissive parenting styles with the potential for enmeshment\u003csup\u003e57\u003c/sup\u003e and co-dependency\u003csup\u003e58\u003c/sup\u003e, affecting attachment\u003csup\u003e59\u003c/sup\u003e, the infant\u0026rsquo;s sense of autonomy\u003csup\u003e57\u003c/sup\u003e, potentially hindering their social and emotional development\u003csup\u003e60-62\u003c/sup\u003e. Furthermore, it highlighted that parents\u0026rsquo; experiences of MAC impacted decisions regarding future family formation.\u003c/p\u003e\n\u003ch3\u003eStrengths and limitations\u003c/h3\u003e\n\u003cp\u003eThe meta-synthesis approach allows for new interpretation of multiple findings, which can be used to inform clinical practice. Scientific rigour and transparency were core features of this review with efforts made to reduce bias at screening, data extraction and quality appraisal, with the incorporation of independent reviewers. This review included studies written in different languages, allowing the incorporation of experiences of individuals from different countries and cultures. Similarities were identified across the included studies, suggesting an acceptance and universality of experiences internationally. The findings explored a broad range of experiences both during pregnancy and parenting, something that has not been achieved before.\u003c/p\u003e\n\u003cp\u003eWhilst this meta-synthesis focused on the experiences of pregnancy and parenting following MAC, some caution is necessary for the interpretations and generalisation of previous findings to this study. The review identified a bias of MAC in the context of subfertility with 19 of the included papers recruiting only participants with a history of fertility challenges. Therefore, it is difficult to disentangle whether their experiences are the result of MAC, subfertility, or an interaction of both.\u003c/p\u003e\n\u003cp\u003eTo support scientific rigour, the grey literature was excluded. However, this may have introduced publication bias and excluded additional papers. Although the majority of studies had good methodological quality, thereby enhancing the trustworthiness of findings, none of the included studies sufficiently referred to reflexivity, an essential component in qualitative literature. Only two studies\u003csup\u003e30,31\u003c/sup\u003e received a low quality rating; however, the knowledge extracted from these papers did not heavily influence the overall findings. Despite best efforts to include all relevant results, two studies met all other relevant inclusion criteria but failed to report the method of MAC \u003csup\u003e63, 64\u003c/sup\u003eThus, it was not possible to ensure that the study sample included individuals pregnant/parenting after advanced MAC techniques (as opposed to after OI/IUI only). Attempts to clarify this information with the authors were unsuccessful. It is possible these studies were relevant to the review but were excluded on this basis. Finally, six articles (two Japanese, four Portuguese) were translated into English. Whilst these were checked for accuracy by native speakers, these were not professional transcribers; therefore, meaning may have been lost in translation.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;There was a lack of consistency across papers in reporting the ethnicity of participants. Additionally, when ethnicity was reported, most participants were from white backgrounds. Therefore, the views of parents from black and minority ethnic (BAME) groups remain under-represented in the literature.\u003c/p\u003e\n\u003ch3\u003eResearch implications\u003c/h3\u003e\n\u003cp\u003eWhilst the findings identify the challenges and difficulties experienced by groups of parents, further research is necessary to determine what kind of support individuals find helpful during pregnancy and parenting. As this review identified a significant bias towards MAC in the context of infertility, further research is necessary with mixed samples or those who sought MAC for alternate reasons, such as being in a same-sex couple or a solo parent. Qualitatively exploring the perspectives of these individuals would allow a more holistic picture, further disentangling the impact of MAC and infertility on experience.\u0026nbsp; Furthermore, the views and experiences of parents from BAME backgrounds are under-represented in the current literature, which is a priority for future research.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eClinical implications\u003c/h3\u003e\n\u003cp\u003eAs part of this systematic review, the psychological, social and health care needs of individuals during pregnancy and parenting following MAC were extracted and synthesised, with suggested clinical recommendations (Table 4).\u003c/p\u003e\n\u003cp\u003eTable 4: Psychological, social and health care needs of parents following MAC with clinical recommendations\u003c/p\u003e\n\u003ctable width=\"1030\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003e\u003cstrong\u003eNeeds\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"652\"\u003e\n\u003cp\u003e\u003cstrong\u003eClinical recommendations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e\u003cstrong\u003ePsychological\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003ePotential anxiety in pregnancy.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"652\"\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Increased awareness of potential psychological distress and adjustment difficulties amongst health professionals in maternity services who provide care for individuals pregnant after MAC.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Psychological service provision which validates the potential psychological challenges within this client group\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Clinical Health Psychologists embedded within maternity services to disseminate psychological thinking, provide containment and intervention on an individual and systemic level.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Training for health professionals in identifying, monitoring and screening of emotional well-being for all individuals who successfully achieve pregnancy following MAC.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; The offer of psychological support during MAC and resultant pregnancy to help individuals integrate and process their experiences, if required.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Consideration of the longer-term psychological needs to be considered incorporating difficulties relating to transition in identity and role. This could be achieved via psychologically informed antenatal and parenting groups or the offer of one-to-one therapeutic sessions focusing on the parent-infant relationship and bond.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e\u003cstrong\u003eSocial\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eThe possibility of feeling excluded and marginalised.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePossible reluctance to share distress and experiences due to fear of judgement, shame and stigma.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"652\"\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Normalisation and peer support groups to be offered to help reduce feelings of exclusion.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Incorporation of sociocultural factors such as religious values and beliefs when conducting assessment\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Individuals to be signposted to appropriate support services, if required.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e\u003cstrong\u003eHealthcare\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"265\"\u003e\n\u003cp\u003eReassurance and containment.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"652\"\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Promotion of consistency of care with MAC-aware midwives (in the absence of indication for consultant led care) antenatally and postnatally where individuals can develop trusting relationships with familiar health professionals\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Specialist training provided to midwives and consultants in relation to pregnancy and parenting after medicalised conception and infertility.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Health professionals to be proactive in fostering non-judgemental spaces, enquiring about the impact of MAC, validating experiences.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis review highlights the significant psychosocial impact of MAC impacting antenatal and early parenting experiences, exacerbated by the sociocultural context. As evidenced, this can lead to unmet care needs, delayed help-seeking and acts of protection. \u0026nbsp;A need for increased monitoring of parents\u0026rsquo; emotional well-being and adjustment to pregnancy and parenting is required. Continuity of care and specialist training for health professionals is necessary to ensure services identify and meet the needs of those who successfully conceive via MAC.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Not applicable. As this was a review of published papers, it did not require ethical approval or participant consent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors consent for this review to be published.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they do not have any competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZF: Conceptualization, methodology, formal analysis, investigation, writing-original draft, visualisation, project administration. LH: Conceptualisation, methodology, writing \u0026ndash; review and editing. DS: Conceptualisation, methodology, formal analysis, writing \u0026ndash; review and editing. AW: Conceptualisation, methodology, investigation, writing \u0026ndash; review and editing, supervision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgments\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research team acknowledge the work of Emmeline Joyce for her role within the screening process. Similarly, Farhan Rahman is acknowledged for his role in the quality appraisal and Zaynab Khan for her assistance with the final formatting of this manuscript. Farhan and Zaynab were associated with the Perinatal Mental Mental Health and Parenting (PRIME) Research Unit within Greater Manchester Mental Health NHS Foundation Trust.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHuman Fertilisation and Embryology Authority (2019, May). Fertility treatment 2017: trends and figures. https://www.hfea.gov.uk/media/2894/fertility-treatment-2017-trends-and-figures-may-2019.pdf .\u003c/li\u003e\n\u003cli\u003eCentre for Disease Control and Prevention. (2021). \u003cem\u003eAssisted Reproductive Technology: Fertility Clinic and National Summary Report. \u003c/em\u003eAccessed 11/12/2021: \u003cem\u003ehttps://www.cdc.gov/art/reports/2019/pdf/2019-Report-ART-Fertility-Clinic-National-Summary-h.pdf\u003c/em\u003e\u003c/li\u003e\n\u003cli\u003eWyns, C., De Geyter, C., Calhaz-Jorge, C., Kupka, M. S., Motrenko, T., Smeenk, J., \u0026amp; Goossens, V. (2021). 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DOI: 10.3316/ielapa.198965423109935.\u003c/li\u003e\n\u003cli\u003eHuang MZ, Sun YC, Gau ML, Puthussery S and Kao CH (2019) First-time mothers\u0026rsquo; experiences of pregnancy and birth following assisted reproductive technology treatment in Taiwan. \u003cem\u003eJournal of Health, Population and Nutrition\u003c/em\u003e 38(1): 1-11. DOI: 10.1186/s41043-019-0167-3.\u003c/li\u003e\n\u003cli\u003eLaville, C., \u0026amp; Dionne J. (1999). The construction of knowledge: manual of research methodology in human sciences. trans. \u003cem\u003eHelo\u0026iacute;sa Monteiro e Francisco Settineri. Porto Alegre: Artmed\u003c/em\u003e.\u003c/li\u003e\n\u003cli\u003eSmith, Flower, P., \u0026amp; Larkin, M. (2009). \u003cem\u003eInterpretative phenomenological analysis: Theory, method and research\u003c/em\u003e. London: Sage.\u003c/li\u003e\n\u003cli\u003eBoeije, H. (2008). Analyzing in qualitative research. \u003cem\u003eThinking and doing\u003c/em\u003e. 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Boston MA: Allyn \u0026amp; Bacon\u003c/li\u003e\n\u003cli\u003eCharmaz, K. (2014). \u003cem\u003eConstructing grounded theory\u003c/em\u003e, 2nd ed. SAGE Publications.\u003c/li\u003e\n\u003cli\u003eFrost N (2010) \u003cem\u003eQualitative Research Methods in Psychology: Combining Core Approaches\u003c/em\u003e. Milton Keynes: Open University Press.\u003c/li\u003e\n\u003cli\u003eGreg, M., Asahara, K., Yokoyama, M. (2007). \u003cem\u003eHow to proceed and summarize qualitative research Aiming to be an expert in nursing research\u003c/em\u003e. Tokyo: Medical and Dental Publishing\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pregnancy, parenting, antenatal, postnatal, assisted reproduction","lastPublishedDoi":"10.21203/rs.3.rs-2136464/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2136464/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/em\u003e Medicalised Conception (MAC) assists many couples to achieve pregnancy worldwide. As the impact of MAC has been linked to increased pregnancy-specific anxiety and parenting difficulties, this review aimed to explore parental experiences of pregnancy and early parenting following MAC, identifying their psychological, social and health needs.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethod:\u003c/strong\u003e\u003c/em\u003e Five databases were searched systematically. Identified articles were screened for eligibility. Twenty qualitative studies met inclusion criteria and results were analysed using thematic synthesis. The Critical Appraisal Skills checklist was employed to appraise methodological quality.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/em\u003e The findings were synthesised into three main themes: 1) \u003cem\u003eThe vulnerable parent: fear, doubt, uncertainty, \u003c/em\u003e2) \u003cem\u003ethe stark realisation of the parental dream, \u003c/em\u003e3) \u003cem\u003epsychosocial needs and support.\u003c/em\u003e Parents lacked a sense of safety during pregnancy and acted protectively, both antenatally and postnatally\u003cem\u003e. \u003c/em\u003eIdentity transition was complex and non-linear, influenced by sociocultural context.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/em\u003e Considerable unmet psychosocial needs were identified with a need for consistent, holistic care, integrating psychological services.\u003c/p\u003e","manuscriptTitle":"Parents' experiencees of life after medicalised conception: A systematic review and thematic meta-synthesis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-10-24 14:38:22","doi":"10.21203/rs.3.rs-2136464/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-11-28T11:09:56+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-11-02T04:17:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"36da91b4-d6d7-4e83-bff1-2a37c6bd884d","date":"2022-10-30T09:52:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-10-26T23:09:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-10-26T23:06:37+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-10-19T11:57:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-10-19T11:53:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2022-10-05T21:27:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8826917b-36f4-4e92-b617-aaab27824585","owner":[],"postedDate":"October 24th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T22:09:02+00:00","versionOfRecord":{"articleIdentity":"rs-2136464","link":"https://doi.org/10.1186/s12884-023-05727-x","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2023-07-17 21:42:09","publishedOnDateReadable":"July 17th, 2023"},"versionCreatedAt":"2022-10-24 14:38:22","video":"","vorDoi":"10.1186/s12884-023-05727-x","vorDoiUrl":"https://doi.org/10.1186/s12884-023-05727-x","workflowStages":[]},"version":"v1","identity":"rs-2136464","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2136464","identity":"rs-2136464","version":["v1"]},"buildId":"DiO0y1XJrWGSkZWLOoVa_","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}