Women's needs in their journey towards motherhood via oocyte donation: A mixed methods systematic review

Abstract Background Given the significant changes in family formation through donation procedures, providing an optimal level of care that is responsive to the needs of mothers who get pregnant via oocyte donation is pivotal to improve their maternal role. Therefore, it is necessary to recognize the needs of oocyte donation mothers to address their specific needs. Objective This study aimed to review the needs of women in their journey towards motherhood via oocyte donation. Materials and Methods In this systematic review, which followed the updated Joanna Briggs Institute's methodological guidance for conducting a mixed methods systematic review, the quantitative observational and qualitative studies were searched through databases including PubMed, Web of Science, PsycINFO, the Cochran Library, and Google Scholar search engine. Letters to the editor, commentaries, magazine articles, articles without full text and abstracts presented in congresses were excluded. All English-language articles related to the needs of oocyte donation mothers, without time limitation, were reviewed. The eligible studies were critically appraised independently by 2 researchers. Results 4649 records were identified from those 18 articles were finally included in the review. The needs of oocyte donation mothers comprised 8 categories: The need for special services in fertility clinics, the need to improve the quality of care, the need for emotional support and psychological consultation, information needs, the need for financial support, the need for disclosure counseling, educational needs, and the need for sociocultural and religious support. Conclusion This review suggests various needs of oocyte donation mothers. The results can be used in carefully planning supportive programs for this vulnerable population.


Introduction
Along with a rise in delaying parenthood and an increase in seeking assisted conception, oocyte donation as the last treatment is increasingly leading to motherhood for millions worldwide (1)(2)(3). Nearly to the family they have built and, to some extent, rework their allegiance to cultural norms to suit their own needs" (5). It has been reported that some mothers are conflicted about their maternal role and did not feel like the mothers who had their child until later in the first year. It has also been hypothesized that mothers, over a longer period of time, will have to put in more emotional effort to understand the child as their own (2).
Given the challenges of parenthood following oocyte donation and ambivalence over the transition to a pregnant identity, these families may benefit from professional support to manage their issues and adjust to this transition (6). Positive pregnancy and childbirth experiences depend partly on receiving services from experienced counselors, realizing donation mother's expectations, and a well-functioning oocyte donation program (7)(8)(9). Proper preparation and careful planning for parenthood and satisfaction with successful treatment can decrease mental health problems in oocyte-donation mothers (10).
The fact is that with the extensive changes in family formation through oocyte donation, it is considered necessary to revise the psychosocial and lifelong needs of these women from pre-treatment onward (11). Providing an optimum level of care and services that are responsive to the needs of these mothers is key to improving their maternal role. Further studies are needed to recognize the facilitating and constraining factors in healthcare. Awareness of the needs of women who finally get pregnant after fertility treatment is necessary for midwives and healthcare professionals (12). Yet, no research has comprehensively and systematically investigated the needs of oocyte donation mothers during pregnancy, birth, and motherhood. Also, there is no national guideline in this regard (13). So, a wideranging review is needed to collect the available data and make the evidence accessible to provide the basis for tailoring appropriate support programs for oocyte donation mothers.
The present study therefore aimed to address this issue and identify the needs of oocyte donation mothers by systematically identifying, appraising, summarizing and synthesizing the relevant literature to address the specific needs of this vulnerable population.

Design
This review is a mixed methods systematic review of qualitative and quantitative studies. to combine quantitative and qualitative data (14).
The reporting of this systematic review was guided by the reporting guideline for meta-analyses of observational studies in epidemiology (MOOSE) (15).

Data sources and search strategy
The articles were extracted from databases including PubMed, ISI Web of Science, PsycINFO, the Cochran Library, and the Google Scholar search engine up to August 2022. In addition, the references cited in the retrieved articles were also searched, manually. The search was performed extensively using Boolean operators with 3 groups of keywords using MESH terms including "oocyte/egg/gamete donation", "women/pregnant women/mothers/motherhood/parents", "need/supportive care", "healthcare", and "emotional health", in all possible combinations.

Study eligibility criteria
Eligibility criteria for the review included quantitative observational studies, including cross-sectional, case-control, and cohort studies, as well as qualitative studies with any design in English language related to the needs of oocyte donation mothers without time limitation. Duplicate and unrelated papers, articles without a full text, letters to the editor, commentaries, magazines articles and abstracts presented in congresses were excluded.

Selection process
Titles and/or abstracts of retrieved studies using the search strategy and those from other sources were screened by 2 authors independently to potentially identify studies that met the eligibility criteria of this review. The full text articles were then assessed for eligibility independently by H.J and R.L.R.

Data collection process
Firstly, it was decided to collect the data related to the study including author, year of publication, setting, design, sample, data collection tools, results, and quality score. The data were then extracted independently by 2 reviewers and entered into a checklist planned by the research team beforehand.

Quality assessment
The eligible studies with the inclusion criteria were appraised independently by 2 reviewers, using strengthening the reporting of observational studies in epidemiology STROBE statement (16). Also, qualitative studies were assessed based on the Joanna Briggs Institute critical appraisal checklist for qualitative research (17). The researchers discussed any disagreements to resolve them. Finally, 3 studies were excluded due to poor quality. Other studies were evaluated as moderate and good and had adequate quality to enter the study.

The method of synthesis
To integrate qualitative and quantitative data in a way that fully informs the topic, one approach is transforming data into a mutually compatible format. Data transformation was carried out by converting quantitative data into qualitative data (i.e., qualitizing), which refers to quantitative data
Out of 18 studies, the design of 7 studies was observational and 11 studies were conducted using qualitative approaches. In total, 8 categories of needs were extracted: the need to special services in fertility clinics (4 studies), the need to improve the quality of care (3 studies), the need for emotional support and psychological consultation (12 studies), information needs (6 studies), the need for financial support (2 studies); the need for counseling about disclosure (9 studies), the need for education and future research (5 studies), the need for sociocultural and religious support (7 studies) ( Table I).
Previous experience with infertility treatment, years of distress, loss, and the "grief work" with infertility are not easily erased and may be ongoing after the child's arrival, discouraging parents from preparing for birth and parenthood. Still, it can be included in a functional and healthy sense of self, with attention to the needs of women from the beginning of treatment until after birth (4,32). So, in this study, the needs of women during the entire process of accepting oocyte donation and treatment till after delivery were investigated.    4

Need to improve the quality of care
Another category of needs was the need to quality of care improvement, including attention to various aspects of antenatal care, pre-donation counseling, care provided by the fertility clinic staff, client-oriented care, and physicians' empathy (12).

Need for emotional support and psychological consultation
Most of the concerns that these families

Information needs
These needs are about providing information about the process of treatment and well-researched data for parents about the donor's age, profession, physical appearance, hobbies, place of residence, characteristics, medical history, race, smoking, alcohol and narcotics use, predominantly on medical and genetic history, personality, and intelligence, details of donor screening and matching, and oocyte allocation (12,22,27). Other information needs include the need to provide visual aids, written information, and a guidance booklet describing the procedure in more detail, such as potential risks, side effects, and long-term consequences and finally, the need to share the experiences (20).

Need for financial support
The need for financial support for patients with lower incomes and decreasing fertility treatment costs with oocyte donation was reported in the studies by Ahuja et al. and Imrie and co-workers (2, 20).

Educational needs
High knowledge and skill levels are required in fertility clinics (23

Need for sociocultural and religious support
Egg donation mothers need to sociocultural and religious support for lowering social pressure, gaining public acceptance, and reworking their allegiance to cultural norms to suit their own needs (5,24,25,27,28). Additionally, addressing the sociocultural factors and using a holistic care approach, considering the psychological, social, and spiritual needs of mothers, and resolving their religious restrictions, seemed necessary (24,28).

Discussion
The present study aimed to review the needs of women who get pregnant via oocyte donation.
The needs in these women comprised 8 categories including the need for special services in fertility clinics, the need to improve the quality of care, the need for emotional support and psychological consultation, information needs, the need for financial support, the need for disclosure counseling, educational needs, and the need for sociocultural and religious support.
The need for fertility clinic support services was one of the needs of women in this review. Women's experience and satisfaction are affected by clinic support services, such as providing consultation conditions to people far from the clinic and introducing a known donor because some infertile women cannot find a known donor (30,33). In a qualitative study, the need to offer counseling via video conferencing for women far from the clinic was discussed.
The need to improve the quality of care and providing person-centered care by clinics was another result of this review (34). Donation mothers expected a normal pregnancy but need care different from normal midwifery practice (12). In The need for emotional support and psychological counseling at the infertility clinic has been emphasized in all 18 studies reviewed.
Evidence suggests that becoming pregnant after fertility treatment and oocyte donation, like a double-edged sword, comes with many complex psychosocial issues and difficulties in the transition to parenthood, leading to perinatal morbidity (13).
The journey of these forgotten women during the process of achieving treatment and successful pregnancy is often overlooked. Egg donation mothers often suffer from grief, disappointment, and experience ambivalent feelings (2,9,12). In the study by Imrie and co-workers, one woman described the lack of genetic link as a bit heartbreaking and still as an struggle at times to feel whether her child is completely hers, instead of imagining the donor as the mother of her child (32). Maternal distress could have more negative impact on children who have been informed of their origins (36). A growing body of evidence demonstrates that this group of women has specific psychological issues, which undoubtedly increases the need to attention (13).
Oocyte donation couples must see a psychologist at least once. They are allowed for treatment if there was no problem after the screening for psychological status (7). The anxiety and fear of pregnancy are affected by the health professionals' support in primary care (6). Also, introducing examples of non-genetic close relationships can convince the parents that genetic connections are not essential in forming loving relationships (2).
Therefore, long-term psychological counseling, during and after the donation process, with a mental health professional in the fertility clinic before pregnancy may improve women's psychological status (7)(8)(9).
The need for information was another important needs of oocyte donation mothers in this review.
Before becoming pregnant, women should receive information about the potential risks of pregnancy as well as the health of newborn at a fertility clinic (7 oocytes is a social issue, and the formation of families using it brings sociocultural challenges (20,42,43). Some women experience stigma related to the non-genetic parenthood and confront it as badly reacted to by family and friends (32,42). The way of its management depends on the meaning and perception by both the individuals involved in the third party reproduction and the social context within which they live; this needs public acceptance (5,11). The surroundings of pregnant women affect their physical and mental health, also their child's prenatal development. An aware community could eliminate infertile couples' concerns and help them to overcome their problems (9). Finally, considering the need of egg donation mothers' to religious support, it is needed that in addition to the infertility care team, which pays attention to all the individual, psychological, social, and spiritual needs of infertile couples, religious scholars should also try to provide religious support through clarifying religious rules to the infertile patients (24).
The limitation of this study was using only English language publications. Also, despite our thorough search process, we may have missed or inadvertently excluded some relevant articles.
However, to the best of our knowledge, this is the first systematic review conducted regarding the needs of oocyte donation mothers. Also, using of a comprehensive search strategy, over a longer period, systematically using studies conducted with different designs with mixed methods systematic reviews is the strength of this review and indicates the validity of the study findings.

Conclusion
This study is the first systematic review of