Advances in assisted reproductive technology (ART)
offer new methods of getting pregnant and make parenthood
possible for people deprived of having children
for various reasons (
Deciding to use these technologies is influenced by
people’s perceptions and the society’s expectations and
attitudes toward their use (
Deciding about the use of donor conception services is therefore a complicated and difficult process for couples which challenges their values and beliefs. Making this decision is a complicated social and interactive process that is under the influence of various individual, social, economic, cultural, psychological and ethical factors and is affected by the couple’s interactions with each other and with their family, friends, health workers, key people, etc. It is therefore necessary to develop a scale for identifying the determinants of infertile couples’ decision about using donor conception to perform supportive interventions that improve the decision-making process and reduce the outcomes of the decision including regret. A review of the literature did not show any instruments developed for direct measurement of the subject in question. Given the complexity of the decision-making process about this issue and the absence of an instrument for its assessment, the present study was conducted to fill the gap, develop a decision-making for donor conception questionnaire (DMDCQ) and determine its psychometric properties in Iranian infertile couples.
The scale developed in this study measures the determinants of infertile couples’ decision-making and can help specialists to understand the issues around infertile couples’ decision making concerning the use of ART and design individual and public training programs and instructional decision-making packages for resolving the barriers and thus reducing the need for unnecessary interventions.
This cross-sectional validation study was performed
using the method developed by DeVellis in 2012 (
In the first step, the concept under measurement (i.e. decision-making for donor conception) was theoretically defined. For the first step and in order to explain participants’ experiences regarding the process of decision- making for donor conception, a qualitative study with a grounded theory approach was performed in 2014 in Mashhad, Iran, using individual interviews. A total of 38 participants including nine eligible infertile couples (four couples who were candidates for receiving egg donation, three couples candidates for receiving embryo donation, one couple candidate for receiving egg and uterus donation and one couple candidate for receiving uterus donation) and 14 eligible women (seven egg donor candidates, four embryo donor candidates, one egg and uterus donor candidate and two uterus donor candidates), were enrolled. The key people involved in decision-making for donor conception, including two gynecologists, two midwives and two clergymen, were also interviewed during the theoretical sampling, and this process was continued until the saturation of the categories without any restrictions on the number of participants and according to the theoretical requirements of the study.
The inclusion criteria were being married, Iranian, and infertile (either male or female infertility or both), having no biological or adopted children, nor other spouses, having the experience of using at least one ART in the past or being under treatment with ART or in the waiting list to receive ART, being willing to participate in the study and being able to communicate and express their experiences. The selected members of the infertility treatment team had at least one year of experience of working with infertile couples. The selected clergymen were experts in this field and were interested in participating in the study. The study was performed at Milad Infertility Clinic, Mashhad, Iran. The participants were selected through purposive convenience sampling with maximum variation in terms of age, duration of infertility, duration of treatment, education and socioeconomic status. Sampling was continued until the saturation of the data. Data collection was mainly done through semi-structured in-depth interviews directed by the interview guide, that enabled the participants to freely discuss the matter. All interviews were done by one of the researchers. The interviews were conducted separately with the infertile men and women, but a couple interview was also held with both the husband and wife if there was an obvious difference in their answers. Each interview took 40-120 minutes and was held in one or more sessions. The interviews were recorded with participants’ permission. Data were analyzed concurrently using MAXQDA-2007 and five dimensions ultimately emerged. The approval of the local Research Ethics Committee of Shahid Beheshti University of Medical Sciences was obtained along with the informed consent of all participants before beginning the study.
In the second step, an item pool was produced using an inductive method; for this purpose, items relevant to the main concepts of donor conception decision-making were developed based on the qualitative findings of the study (n=170). Participants’ attitude toward each item was measured on a 5-point Likert scale from “quite agree” to “quite disagree”.
In the third step, the initial items extracted from the qualitative study were reviewed by the research team and the repetitive and ambiguous items were removed. Eventually, 113 items were developed in five dimensions, including being offered to use donor conception (10 items), inner turmoil (4 items), attempts for coping with the current conditions (23 items), deciding to accept and use donor conception (54 items) and deciding to undergo treatment (22 items).
The face validity of the questionnaire was evaluated
both qualitatively and quantitatively in the fourth step.
To perform the qualitative evaluation, face-to-face interviews
were conducted with ten similar members of the
target group (four infertile men and six infertile women
who met the inclusion criteria) and difficulties in understanding
the words and phrases, the degree of inappropriateness
of the phrases or their irrelevance to the questionnaire
dimensions, ambiguities causing misunderstanding
of the phrases, or the words failing to convey a meaning,
were examined. Once the items were modified according
to the received feedback, the item impact was measured
quantitatively. The objective in this step was to determine
the item impact score in a sample that was similar to the
target group. For this purpose, each item was scored on
a 5-point Likert scale as follows: 5: “quite important”,
4: “somewhat important”, 3: “relatively important”, 2:
“slightly important”, and 1: “not important at all”. Ten
individuals similar to the target group (four infertile men
and six infertile women who met the inclusion criteria)
were asked to determine the importance of each item
based on their own experiences. The researcher calculated
the impact score (IS) for each item separately based on the
following equation (
Impact score=Frequency percentage×level of significance
Frequency percentage=The percentage of all the people who have reviewed each item
The items with an IS <1.5 were considered inappropriate
and removed from the questionnaire (
The content validity of the questionnaire was evaluated both qualitatively and quantitatively. For the qualitative assessment of the content validity, the questionnaire was distributed among ten specialists (Ph.Ds in reproductive health or health education, and a number of gynecologists) and they were asked to give their feedback on the questionnaire. The content validity ratio (CVR) and content validity index (CVI) were used for the quantitative assessment of the content validity.
To determine the CVR, ten specialists were asked to review
each item on a 3-point scale (3: necessary, 2: useful
but not necessary, and 1: not necessary). The CVR was
then calculated based on Lawshe’s formula as follows
ne: The number of specialists who have selected the “necessary” response
Based on Lawshe’s Table of minimum values, items
with a CVR >0.62 as per the evaluation of the ten specialists,
were deemed significant (P<0.05) and remained in
the questionnaire (
The CVI for each item was examined based on the Waltz
and Bausell CVI and the three criteria of simplicity, specificity
(relevance) and clarity were separately measured on
a 4-point Likert scale by the ten specialists. To calculate
the CVI for each item, the total number of specialists who
had given 3 and 4 points (i.e. the highest score) to that item
was divided by the total number of specialists (n=10). The
items with a CVI >0.79 were deemed acceptable (
After determining the face and content validity, the initial reliability was calculated as the item analysis index. For this purpose, 30 infertile men and women visiting the infertility clinic were selected by convenience sampling to complete the initial questionnaire, and the Cronbach’s alpha was calculated to determine the internal consistency for each factor as well as the entire scale. Cronbach’s alpha values of 0.7 were considered favorable in this study.
The construct validity was determined by exploratory factor analysis. For analysis of the data, the exploratory factor analysis was performed in seven steps: determining the sample size, examining the correlation between the items, deciding about the items being fit for the factor analysis, determining the number of initial factors extracted, rotating and extracting the final factors and naming the factors.
According to Tabachnick and Fidell (
The correlation between each item and the other items was examined by principal component analysis (PCA), and the items that had correlation with the other items of <0.3, were eliminated from the analysis.
The Kaiser-Meyer-Olkin (KMO) measure of sampling
adequacy was used to ensure the adequacy of the
samples. If the KMO measure is >0.70, the set of data
is deemed fit for factor analysis. Bartlett’s test of sphericity
was also used to examine the fit of the data for
the factor analysis. If the P value is <0.05 in this test,
factor analysis is considered an appropriate technique
The reliability of the questionnaire was examined
using the internal consistency and test-retest stability
methods. To measure the internal consistency, 30 infertile
men and women visiting Milad Infertility Clinic
were selected by convenience sampling to complete
the questionnaire, and Cronbach’s alpha values were
calculated for each factor and the entire questionnaire.
Cronbach’s alpha values of =0.7 were deemed acceptable.
To determine the stability of the questionnaire,
20 infertile men and women completed the questionnaire
within a two-week interval and the intraclass correlation
coefficient (ICC) was then calculated. An ICC
>0.70 was deemed acceptable (
A total of 220 infertile men and women who met the inclusion criteria participated in this psychometric assessment. Table 1 presents the demographic and infertility characteristics of the participants.
The demographic and infertility-related characteristics of the participants
|Participants’ characteristics||n (%) or|
|n=220||mean ± SD|
|Below high school diploma||50 (22.7)|
|High school diploma||72 (32.8)|
|Associate or bachelor’s degree||86 (39.1)|
|Master’s degree or higher||6 (2.7)|
|No answers||6 (2.7)|
|Age (Y)||29.7 ± 5.08|
|Infertility duration (month)||63.4 ± 43.2|
|Treatment duration (month)||34 ± 32.5|
|Ovarian and uterine||15 (6.8)|
|Male factor||56 (25.5)|
|No answers||20 (9.1)|
|Family history of infertility|
|No answers||4 (1.8)|
SD; Standard deviation.
Based on the results of the qualitative content analysis, an item pool was composed of 170 items, and the ambiguous and repetitive items were removed after the revision done by the research team. Eventually, 113 items were developed in five dimensions or constructs, including being offered to use donor conception (ten items), inner turmoil (four items), attempts for coping with the current conditions (23 items), deciding to accept and use donor conception (54 items) and deciding to undergo treatment (22 items), which entered the psychometric assessment phase. The evaluation of face validity, which was performed qualitatively and quantitatively, led to the removal of eight items, and the questionnaire entered the content validity evaluation stage with 105 items. The content validity was also evaluated both qualitatively and quantitatively and 28 items were removed, leading to the existence of 77 items. In the stage of initial reliability evaluation, the Cronbach’s alpha was calculated separately for each item, eight items were removed, and the remaining 69 items entered the construct validity evaluation stage. It should be noted that the questionnaire’s reliability increased to over 0.7 once these items were removed, and according to the researcher, their removal did not destroy the basic information required. The initial Cronbach’s alpha calculated for the entire scale was 0.82.
To determine the construct validity of the scale, 220 participants were selected through convenience sampling to complete the questionnaire. There was no sample dropout. The collected data were entered into SPSS-22. The PCA showed that the correlation between two of the items and the other items was <0.3; thus, both of these items were removed and the factor analysis was continued with 67 items. The KMO measure for the items was 0.768, which indicates the sampling adequacy. The Bartlett's test of sphericity showed the fit of the data for the factor analysis with P<0.001. The community statistic was >0.4 for most of the items in this study and the items were thus considered fit for factor analysis. Five items with a community statistic <0.4 were excluded from the study, and the factor analysis was continued with 62 items. Determining the number of factors constructing the questionnaire using the factor analysis of the items led to the identification of seven factors with eigenvalues >2 and explaining 48.796% of the total variance. The items were rotated and categorized in each factor using a varimax rotation. Of the 62 items that entered the factor analysis in this study, 51 items and seven factors remained.
The factors were named based on the meaning of
their items, especially the meaning of the item with
the maximum factor loading, and with regard to the
correlation found between the items and the available
theoretical knowledge. The researcher referred to the
qualitative part of the study and the categories and subcategories
forming each item, in order to name the factors
The factor loading of the Desision-Making for Donor Conception Questionnaire items in Iranian infertile couples
|The treatment team’s commitment to keep my information confidential is important to me to accept donor conception.||0.622|
|The positive experiences of people who have used donor conception affect my decision to accept this method.||0.608|
|The treatment team’s honesty in explaining the cause of infertility affects my decision to accept this method.||0.577|
|The infertility clinics’ provision of clear information about the costs of donor conception affects my decision to accept this method.||0.559|
|I need more time for making a decision to accept this method.||0.558|
|I may have to accept donor conception in order to save my marriage.||0.554|
|Clergymen’s approval of donor conception helps me to decide about these methods more quickly.||0.552|
|The existence of laws about donor conception affects my decision to accept this method.||0.542|
|The society’s familiarity with donor conception helps me to accept this method easier.||0.531|
|Consulting sessions held before and during treatment with donor conception affect my decision-making.||0.469|
|The failure to provide clear and proper information about donor conception affects my decision to accept this method.||0.459|
|I may have to accept donor conception in order to free myself of other people’s babble.||0.455|
|Other people’s refraining from interfering in our childbearing or way of childbearing affects my decision to accept this method.||0.427|
|The belief in God’s will makes me peaceful and affects my decision about whether or not to accept this method||0.718|
|When offered to use donor conception, changes in lifestyle, such as working more, make me think less about my problem and make a more rational decision.||0.539|
|When offered to use donor conception, thinking about positive issues makes me calmer and enables me to make a more rational decision.||0.535|
|The possibility of concealing the matter from others affects my decision about whether or not to accept donor conception.||0.714|
|If I use donor conception, I won’t inform others of my decision, because I fear their negative reaction (blaming, humiliation and ridicule) toward myself and my child||0.688|
|If I decide to use donor conception, I will hide it from my child.||0.681|
|If I decide to use donor conception, I may change my job or address||0.558|
|If I decide to use surrogacy services, I will try to pretend to be pregnant.||0.526|
|If I decide to use donor conception, I will inform my first-degree relatives (mother and sister) in order to get support from them.||0.422|
|I feel that if I decide to use donor conception, my emotional relationship with my husband might suffer||0.738|
|I feel that if I decide to use donor conception, my sex life might suffer.||0.726|
|If I decide to use donor conception, I reduce my relationships with others||0.575|
|If I decide to use donor conception, I won’t inquire into the religious aspects of using these methods, because they are being performed in official infertility clinics in an Islamic country||0.564|
|If I decide to use donor conception, I will ask people who have previously used these methods about its religious issues||0.464|
|If I decide to use donor conception, I will seek the fatwa of other religious references in order to reach my goal of having a child, if my own religious reference opposes this method.||0.417|
|If I decide to use donor conception, the donor’s characteristics won’t matter much to me; the only thing that will matter to me is to find the donor faster||0.802|
|If I decide to use donor conception, I won’t inquire much into the donor’s background, because I have to accept her with any conditions due to the limited number of donors||0.731|
|If I decide to use donor conception, I will prefer to use the services of a donation center in order to avoid future disturbances by the donor||0.696|
|If I decide to use donor conception, I will try not to inquire much into the donor’s background, because it may dishearten her and make her change her mind||0.695|
|If the decision to use donor conception becomes certain, I will prefer a known donor because of her availability and the shorter waiting time||0.580|
|If I decide to use donor conception, I will prefer to use donation centers because I can access the donor faster that way||0.576|
|If the decision to use donor conception becomes certain, I will inquire greatly into the donor’s background before selecting her||0.483|
|If I decide to use donor conception, the donor’s moral health will be the most important selection criterion for me||0.477|
|If I decide to use donor conception, I will prefer an unknown donor because I fear others’ learning of my decision||0.429|
|If I decide to use donor conception, the unavailability of a donor will be one of the main barriers||0.642|
|A better coordination between infertility clinics and the legal authorities shortens the duration of the legal procedures and accelerates the decision to use donor conception||0.567|
|If I decide to use donor conception, I will use a method that best fits my mental conditions||0.604|
|The lengthy and time-consuming stages of donor conception make me delay the decision to undergo this treatment||0.599|
|If I decide to use donor conception, I will choose a clinic that costs less||0.572|
|The support of others (including my spouse and family) accelerates my decision to use donor conception||0.565|
|If I decide to use donor conception, I will choose a clinic that has served longer and has more experienced personnel||0.551|
|The high cost of treatment is a barrier to my decision to use donor conception||0.638|
|If I decide to use donor conception, I will use a method that has the shortest waiting time||0.488|
|The availability of medical facilities at nearby infertility clinics accelerates my decision to use donor conception||0.481|
|If I decide to use donor conception, I will try to resolve the barriers with various solutions||0.449|
Table 3 summarizes the number of items in each subscale and the range of scores for the entire DMDCQ and its subscales.
The range of scores for the total and subscales of the DMDCQ
|Subscale||Number of items||Range of scores|
|Role of social networks||14||14-70|
|The decision to disclose or conceal||7||7-35|
|Challenges in the process of treatment||11||11-55|
Table 4 summarizes the mean and standard deviation of the total and subscale scores of the DMDCQ in the entire sample of participants. When the total score of the questionnaire and the scores of its subscales are higher, higher numbers of individuals make positive decisions and the couple will be more inclined toward donor conception in the future.
The mean and standard deviation (SD) of the total and subscale scores of the decision-making donor conception questionnaire (DMDCQ) in the entire sample (n=220)
|Subscale||Mean ± SD||Min||Max|
|Role of social networks||53.57 ± 8.63||22||66|
|Coping strategies||17.75 ± 2.48||4||20|
|The decision to disclose or conceal||24.75 ± 5.16||11||35|
|Interpersonal relationships||8.41 ± 1.97||3||15|
|Religious quests||10.14 ± 2.76||3||15|
|Donor’s characteristics||30.21 ± 5.26||9||45|
|Challenges in the process of treatment||43.20 ± 7.78||15||55|
|Total||188.50 ± 22.27||115||235|
Min; Minimum and Max; Maximum.
The initial Cronbach’s alpha was 0.82 for the entire scale
and 0.75-0.87 for each subscale. The ICC was >0.7 for
all the factors, which confirms the high reliability of the
The Cronbach’s alpha and intraclass correlation coefficient (ICC) of subscales and the entire questionnaire
|Role of social networks||0.85||0.96|
|The decision to disclose or conceal||0.83||0.91|
|Challenges in the process of treatment||0.87||0.88|
The questionnaire developed in this study is the first and only valid and reliable scale developed and psychometrically assessed in the world, concerning donor conception decision-making. The questionnaire consists of 51 items within seven factors, including the role of social networks, coping strategies, the decision to disclose or conceal, interpersonal relationships, religious quests, donor’s characteristics and challenges in the process of treatment. These seven factors explained 48.796% of the total variance.
A review of the literature showed that no specific scale was developed for donor conception decision-making for infertile couples. Decision-making scales such as Flinders’ decision-making questionnaire and the Melbourne decision-making questionnaire with different numbers of constructs, mostly address general issues.
Flinders’ decision-making questionnaire was developed
in 1982 by Mann, for the measurement of coping patterns
and strategies for decision-making in conflict resolution
and consists of 31 items and three constructs, namely vigilance,
hyper vigilance and defensive avoidance (including
procrastination, buck-passing and rationalization). Mann
et al. (
Decision-making instruments about health issues include
the decisional conflict scale (DCS), which measures
decisional conflict in patients and contains 16 items
and three subscales, including uncertainty in making a
health-related decision, modifiable factors contributing to
uncertainty and perceived effective decision making (
The decision-making scale for women with unplanned
pregnancy is another decision-making scale in gynecology,
which was developed by Nourizadeh et al. (
The general strengths of the questionnaire developed in this study include its specificity and its ease of completion. The average time taken to complete the questionnaire was 10-15 minutes depending on the respondent’s literacy.
One of the limitations of this study was the limited number of samples applying for donor conception in the only governmental infertility center in Mashhad. Other limitations included sampling from the men, as some of their wives opposed to be interviewed. Also, due to the uniqueness of the study tool, it was not possible to compare the results with other countries or check the tool’s empirical validity. Respondent bias was another limitation of this study.
The DMDCQ can contribute to the development of an instructional decision-making package and supportive interventions for improving processes of decision-making and reducing negative physical and psychological outcomes and regrets by informing caregivers and counsellors about the circumstances and procedures of decision- making by couples.