IVF and the Internet (2009)
The use of the internet for IVF information in Greece - trends and patients opinions
Mitera Assisted Reproduction Center
Palmer. G.A, Triantafillou. T, Spiropoulou. I. and Walters R.J
Abstract
Internet use is increasingly perceived as a fast and anonymous information resource. Information can be readily collected in real or historical time globally, and electronic communication provides a fast and inexpensive mode of communication. Here we present the data from a questionnaire posed to 297 patients of an IVF unit detailing their use and perceptions of the Internet for health-related matters. Concurrently we monitored 178 emails derived from our IVF information website over a period of 30 months and report our findings.
A large proportion of patients had Internet access (75%) and used the Internet to research information relating to health issues (69%), and specifically IVF (66%), with many expressing a wish to communicate with their physician as a consequence (86%). In contrast, few emails directly requested IVF treatment (3%). Overall the majority of emails related to questions concerning general IVF treatment (29%), donor oocytes (17%), or donor sperm (10%). A great difference however was observed comparing country of origin. A greater proportion of emails from overseas requested donor egg (39%), surrogacy (8%), or sex selection (5%) as compared to few or none from Greece. We conclude the Internet is both a valuable and now established IVF information resource in Greece, with many patients expressing the wish to directly communicate online with their healthcare provider. The frequency and nature of email use varied greatly depending upon the country of origin, and the implications for medical tourism are discussed.
Introduction
The Internet is broadly perceived to be a fast, easy and anonymous information resource. IVF websites presently serve as a globally accessible medium for the provision of information relating to and the advertisement of fertility healthcare. As communication via email is both fast and inexpensive, patients may readily contact specialists. However, Internet use in Greece however has been regarded as having the lowest broadband Internet use within Europe. Almost three-quarters (73%) of Greeks have never used the Internet, the highest percentage of non-Internet use throughout the 25 member states of the EU, according to figures released by Eurostat, official statistical agency of the EU (Demunter C., 2006).
A previous study (Haagen et al, 2003) has revealed that patients are interested in the use of Internet applications relating to fertility care, and the authors suggested that healthcare providers should actively participate in the development and implementation of more Internet-based tools to assist patients in learning about and selecting healthcare provision. The current study investigates Internet use and demand within the Greek population.
There are presently over 50 IVF units in Greece (EIM, 2006), and many of specialists have a personal website, this paper investigates the relevance of the Internet to Assisted Reproductive Technology (ART) patients by means of an anonymous questionnaire and categorizing emails received over a 30 month period. The prospects and implications for medical tourism and ART healthcare in Greece are discussed.
Methods
Patients attending an IVF clinic in Athens, Greece between 1st October and 31st December 2006 were ask to complete an Internet-related questionnaire. The anonymous questionnaire contained 15 multiple choice questions relating to personal details, opinions and use of the internet.
The number and type of emails attracted by our multi-lingual IVF Information website www.kosmogonia.gr over a 30 month period (1st July, 2003 - December, 2006) were catalogued and their relevance addressed. Emails were segregated according to the following categories: male factor, donor oocytes, donor sperm, surrogacy, PGD/PGS, sex selection, pregnancy, general gynaecology, ART questions, journalist inquiries, job applications/training, legal matters, and emails requesting appointments.
Results
Of 352 questionnaires handed out, 297 were returned fully completed (84%) and used for this study. The participation rate by sex was 36% (109) for males and 64% for females (188). The majority of participants derived from Athens (76%).
The majority of patients in our survey were aged between 31 and 35 (37%), and 81% of respondents were aged between 26 and 40 .
The majority of respondents had Internet access (75%) which was accordingly sub-divided into home access only, work office access only, or both.
The main concern over Internet use voiced was a perceived threat to personal privacy (33%), principally from those who did not have Internet access at the time (59%) rather from than who did (25%).
From the respondents, 83 men and 140 women had Internet access. The vast majority of patients over 31 had Internet access, with the highest percentage use recorded for the age range 31-35, where 97% reported Internet access.
Only 22 had used a chat room while 14 (6%) respondents had contributed to an IVF-related forum or chat room, although not on a regular basis. All respondents had found the participation to have been a rewarding experience.
178 Emails were received from the www.kosmogonia.gr website, 99 of which originated from Greece and 79 from abroad. From an analysis of the emails, it was determined that 41 (23%) were from males, 95 (53%) from females, whilst 42 (24%) of the correspondents were of unknown gender.
Emails were received from a spectrum of individuals across a broad range of interests, although the largest groups of inquiries related to questions about IVF procedure (29%) and donor oocytes (17%). A similar pattern of data was observed in Emails from Greece, although there were significantly fewer enquiries relating to donor oocytes (0% vs 17%), surrogacy (1% vs 4%), sex selection (0% vs 4%), Pre-implantation Genetic Diagnosis ( 2% vs 4%), and proportionately more relating to IVF questions (42% vs 29%) and pregnancy (7% vs 4%).
Amongst correspondence from abroad, as compared to those from Greece, a greater proportion related to donor oocytes (39% vs 0%), surrogacy (8% vs 0%), PGD (6% vs 2%,) and sex selection (5% vs 0%). In contrast, fewer enquiries from abroad related to IVF (14% vs 42%), pregnancy (0% vs 7%) or male infertility (0% vs 10%).
Conclusions
The questionnaire was aided by a large sample size with a good completion rate (297/352, 84%) with a strong representation by both sexes (36% male and 64% female). A large proportion of those undergoing IVF treatment had access to the Internet (75%), with 40% (30/74) of those without access intending to use the Internet at some time in the future. Over half (65%) of the patients undergoing IVF treatment had Internet access both at home and at work. Whilst this appears to contradict Eurostat findings, the data may have been skewed by the fact that those within the IVF treatment group were relatively affluent.
ART patients tended to be more likely to use the Internet than those within Greece as a whole, and Internet use according to age distribution revealed that the vast majority of ART patients over the age of 30 had Internet access. The majority of patients (67%) were from the capital Athens where the IVF unit that conducted the study is located, but no correlation between Internet access and location was made due to the relatively small sample size of those who originated from outside Athens, although by necessity all (four) patients from abroad (1.3% of the total patient sample) had originally communicated via the Internet.
The majority of Internet users had employed the medium to search for ART information (66%) and general health matters (68%), and in general found the information both useful and trustworthy (80%). Surprisingly 80% did not know if their chosen fertility specialist had a website or not, suggesting that referrals are not based upon information derived from the Internet. Unsurprisingly nobody (0/297) said that they would select and IVF clinic based solely upon the contents of their website. Although the choice of ART specialist or IVF unit is not apparently based upon the website content, this does not mean that patients would not like to use the Internet to learn more about their specialist.
Communication was, in theory, a high priority among patients who used the Internet. The perceived threat of the Internet to personal security and confidentiality was 33% overall, with those lacking Internet use reporting a greater rate of concerns than those accustomed to using the Internet (59% vs 25%). Whilst most patients believe that the Internet presents only a minimal threat to their security, patients favored the use of the Internet as a means of communicating with their physician, with some 86% desiring to ask questions via email to their specialist, and 62% preferring to be able to book an appointment online. Although only 10% of internet uses (all women) had ever visited a chat room, two-thirds of those who had, reported using the chat room to discuss IVF matters. All respondents agreed that they had obtained useful information from the Internet, and most patients (60%) welcomed the idea of active participation in an Internet conference.
Although there was a clear tendency for direct contact from the website by email, especially enquiries relating to advice. While apparently agreeing with the concept of email communication with the IVF clinic, a relatively few small proportion of Greeks communicated via email. Approximately 33 emails per annum were received from Greek citizens, with 26 emails per annum received from abroad over the same period.
It appears that Greek citizens are more likely to discuss basic health matters relating to IVF, gynecology, pregnancy and general ART than foreigners. This may be explained by a reticence to seek such information from overseas, or by an adequate provision of such information and services within their native country and tongue.
Most Emails originating from outside Greece related to requests for donor oocytes or for surrogacy. This may be due to the absence of affordability or availability of these resources within the countries of origin. Further, IVF and related questions have religious and ethical implications which may result in Greeks preferring to seek information relating to such issues directly from their fertility care provider.
Questions regarding PGD emphasized B-thalassaemia, due to its high incidence within Greece and the recognized experience of Greek specialists (Palmer et al). Naturally most questions concerning male fertility and pregnancy were gender specific.
The primary aim of an IVF website is to explain and advertise ART services, and accordingly health care providers must carefully consider Internet implementation strategies to best inform, direct and retain web traffic.
Answering medical emails is time consuming and is fraught with legal implications, as responses are seldom brief and it is almost impossible to answer individual cases without detailed knowledge of the case and the patient.
The development of internet applications has great implications for the trend in medical tourism. Many countries have infertility treatments that are either severely restricted or else prohibitively expensive (Matorras, 2005; Heng, 2006).
The most frequent email topic deriving from overseas related to requests for either donor sperm or oocytes, and all legal questions concerned the use and provision of donor oocytes.
Journalists from abroad most frequently asked about the use of donor oocytes, thereby increasing and reinforcing the growing trend towards medical tourism in IVF.
Is the Internet being used predominantly as an information resource for IVF by the media, students and curious individuals, rather than as an online booking and reservation service?
We conclude that the Internet is indeed a valued and established information resource for IVF in Greece. A large increase in the use of the Internet to obtain health-related information has been realized according to a comparison with a pilot survey conducted in 2002 (Palmer, unpublished data). Many it appears would welcome the availability of an Internet-based video or chat room conferencing facility to discuss ART and IVF-related issues.
The Internet remains a prospective source of information for those patients who wish to seek treatment overseas in accordance with Sellars, (2006).Questions relating to the cost and provision of services can be quickly resolved without costly consultation.
References
Demunter C. (2006) How skilled are Europeans in using computers and the internet. April 7, Statistical Office of the European Communities.
European Ivf-monitoring programme (EIM). Assisted reproductive technology in Europe, 2002. Hum. Repro2006 21(7):1680-1697
Haagen E.C., Tuil W., Hendriks J., de Bruijn, R.P.J., Braat, D.D.M., Kremer, J.A.M. (2003). Current Internet use and preferences of IVF and ICSI patients Hum Repro, Vol. 18, No. 10, 2073-2078.
Heng BC. 'Reproductive tourism': should locally registered fertility doctors be held accountable for channelling patients to foreign medical establishments? Hum Repro. 2006 Mar;21(3):840-2.
Matorras R. Reproductive exile versus reproductive tourism. Hum Reprod. 2005 Dec;20(12):3571
Palmer G., Davies S., Kanavakis E., et al. (2002) Pregnancies following pre-implantation genetic diagnosis after blastocyst stage transfer. Hum. Repro. 17(1), 25-31.
Sellars C. Cross border access to healthcare services within the European Union. World Hosp Health Serv. 2006;42(1):23-5
