The written PinK survey of 565 patients in fertility clinics in the south-west of Germany allows insight into the health service pathways of patients at the beginning of infertility treatment in Germany for the first time. It shows that medical needs and utilisation of services differ in men and women with an unfulfilled desire for a child. While nine out of ten women had spoken to their gynaecologists about the unfulfilled desire for a child, every third man had not spoken about the problem to any physician at all prior to their first visit to a fertility clinic. After the urologist, the GP was the most important contact person regarding the unfulfilled desire for a child for men (12.0%), followed by their partner’s gynaecologist. Other specialists such as endocrinologists, haematologists and andrologists were only sporadically. None of the participants stated that they had consulted a specialist for skin and sexually transmitted diseases. Only about every 4th woman and every 10th man had had the conversation about a possible infertility being initiated by their firstly contacted doctor. The patients’ needs differed from this reality: Every third man and even every second women wished that the physician would initiate a conversation about the topic. Additionally, approximately every third man and every fifth woman were indecisive and at least did not reject the idea of a consultation initiated by the doctor. It must be emphasised that only every 9th man and every 4th woman was informed that treatments at a fertility clinic could be emotionally straining, despite binding guidelines for statutory health insurance-accredited physicians requiring that patients have to be briefed on medical, psychological and social aspects of fertility treatment before their referral to a fertility clinic .
When interpreting the results, the reader needs to be aware that only patients of selected fertility clinics were surveyed. These patients only represent the part of the group of individuals with an unfulfilled desire for a child that is using medical services and is potentially accepting health risks due to reproductive treatment. But it is known that 10-50% of all couples struggling with an unfulfilled desire for a child do not seek medical help [10, 11, 26] and in some other cases sufficient medical support can be rendered without the need for a referral to a fertility clinic, for example through monitoring of the menstrual cycle or hormonal stimulation therapy. The PinK study does not give an insight into the medical care received by those infertile couples that do not start treatment at a fertility clinic. It also does not give any information about the selection mechanisms on the way to a fertility clinic or on the factors that decide whether a couple seeks treatment at a fertility clinic.
The following limitations apply to our results:
Selection bias could have occurred at a participation rate of 31%. A test of the study population’s representativeness of all couples at the beginning of infertility treatment was not possible due to the lack data on socio-economic variables for the latter population, e.g. in the German IVF register [14, 15]. It is notable that only very few participants (3.5%) have a “low education level”. It is possible that patients with low income utilise services at fertility clinics less frequently due to the often required financial commitment or inadequate information about treatment options. Future research will have to determine whether access and utilisation of ART treatments are unequally distributed by income in the German health care system. Also, bias in the patient selection by staff members of the fertility clinics handing out the study documents cannot be ruled out. However, this bias should have been counteracted against by the use of standardised inclusion criteria and frequent preventative communication between the coordinating study centre and staff at the fertility clinics.
It is lastly possible that an information bias, especially due to socially desirable response behaviour, may have occurred, although socially desirable response behaviour should have been prevented through ensuring full anonymity in the survey. Information bias was also mitigated by the standardisation of the survey instrument and the preceding pilot study .
A health care gap for men can be identified since approximately one third of male participants did not have any medical conversation about the unfulfilled desire for a child outside the fertility clinic. This result is supported by a recently conducted survey of childless persons in Germany, showing that involuntarily childless men have undergone medical examination for infertility less than half as often as women across all age groups (for example 12% men vs. 46% women aged 40 to 50 years) . Need for counselling for infertile men is indicated since it is proven that male causes of infertility are involved in about 50% of infertile couples in Europe and the US  and that men also experience grief and elevated levels of infertility-related anxiety before and during infertility treatment [2, 28]. On the one hand, it is known that men show a lower general health care utilization than women [29, 30]. On the other hand, there seems to be a lack of a dedicated medical contact person for fertility problems for men as opposed to for women. Medical check-ups at the gynaecologist might lead to a more frequent consideration of a women’s fertility and wish for a child.. Men are lacking a comparable, low threshold contact in the health care system. As the GP is a physician that men might be comparatively regularly in contact with for a number of preventative as well as curative measures, he could be an important and feasible first contact person for men with regard to fertility questions. In Great Britain, the GP is officially recommended as the first medical contact person concerning such matters . There, the majority of patients agrees with the GP’s involvement, only 3% reject it .
Considering that formal support is especially important for infertile men as they are less likely than women to seek informal support in their social network and are more prone to withdrawal , the health care gap for infertile men in Germany urgently needs to be closed. Due to the low threshold, family-oriented approach of GPs and the trust placed in them by men and women alike, they might be able to discuss fertility problems and give medical information on the possibilities of possible treatments. They could also help to lower unrealistically high expectations regarding the prospect of reproductive medical treatments and offer advice regarding alternatives.
A part of the patient collective would like to be approached by their doctor regarding an unfulfilled desire for a child. But in a survey of 25 GPs in a German city for example, only few GPs reported having in fact initiated a conversation about fertility problems . The new findings reported here should motivate doctors to address the topic of fertility and according problems.
It would definitely be of advantage and is also a legal obligation for statutory co-payment for ART treatment in Germany that doctors referring to a fertility clinic inform the patients about treatments, alternatives and possible strain [31, 34]. An earlier study has already suggested that patients wish for more information on the possible psychological strain during the treatment . This information need is further supported by results from a study on childless men and women in Germany that found that far more men and women have heard about treatment measures (e.g. IVF, insemination and sperm or egg donation) than of psychosocial counselling and psychotherapy for persons with an unfulfilled desire for a child. The degree of familiarity with the latter services amounted to only 45%, respectively 46% among men and 53%, respectively 57% among women .