Gatekeepers for infertility treatment? Views of ART providers concerning referrals by non-ART providers

Many patients who might benefit from treatment using assisted reproductive technology (ART) do not receive it, raising critical questions of why, and how best to overcome existing barriers. In-depth interviews of approximately 1 h each were conducted with 27 ART providers (17 physicians and 10 other healthcare providers). These interviewees suggest that non-ART providers may serve as gatekeepers in a complex system, involving not only individual-level, but also dyadic and institutional, processes and factors related to provider-patient relationships. Differences emerge concerning 'who' refers patients for ART (e.g. what types of provider), 'how' (amount, type and specificity of information offered), 'when' (delayed or not) and 'why or why not', and how patients respond to referrals, once made. At least seven types of clinician (general practitioners, obstetricians/gynaecologists, paediatricians, geneticists, psychologists and oncologists) may refer patients. Barriers to referral include indistinct boundaries between specialties and provider discomfort discussing reproduction and sex. These data, the first to explore dynamic factors and processes related to provider-patient relationships and interactions in referrals of patients for ART, suggest several key issues (e.g. non-ART providers' roles as gatekeepers), and implications for future education, practice, guidelines and research, highlighting a research agenda, and the need for targeted education for different groups of clinicians.