This study was a descriptive quantitative cross-sectional questionnaire survey.

Data were collected by purposive sampling of participants from a convenience sample of 4 infertility clinics in the Kanto district of Japan in which the primary physicians and nursing directors have agreed to cooperate with this study. The inclusion criteria were as follows: 1) adult men undergoing infertility treatment, 2) adult men communicating in Japanese, and 3) adult men having no serious physical or physiological medical histories. The exclusion criteria were as follows: 1) patients with sexual dysfunction or severe psychiatric disorders, and 2) patients who received positive results in their pregnancy test. The sample size required for the survey was calculated using the response rate of 0.5, the standard error of 5%, and the confidence level of 95% (λ = 1.96). Therefore, the target sample size was set at 426 participants (384/0.9).

n = 1.96 2 × 0.5 ( 1 − 0.5 ) 0.05 2 = 384

After obtaining permission from the health facilities, verbal and written information regarding the research project was provided to the participants. Submission of the completed questionnaire was considered as indicating consent from the participant. Each participant was asked to return the completed questionnaire in a sealed envelope either by post or by placing it in a collection envelope at the waiting lounge of the clinic. During the study period from April to August 2016, 411 questionnaires were distributed to eligible patients. A total of 332 (80.8%) completed questionnaires were returned, of which 321 were suitable for analyses.

The study was conducted after obtaining approval from the Ethics Committee for Epidemiological Studies at Tokyo Healthcare University (approval no. 27-33) dated January 20, 2016. Following the Declaration of Helsinki, a written explanation regarding the study objectives, methods, protection of anonymity, and voluntary basis of participation was provided to each participant. It was also explained that the collected data would only be used for this study.

Descriptive statistics of quantitative data were calculated. The presence and absence of care needs of male patients were examined between 2 groups according to their attributes using the chi-squared test. SPSS version 23.0 (SPSS, Chicago, IL, USA) was used for data analyses at a significance level of 5%. The qualitative data from the open-ended remarks regarding the medical care requests were analyzed in terms of the description of the contents qualitatively and recursively. By noting the context described, this was coded during the comparison while considering the similarities and differences. When the level of coding abstraction was raised, this generated categories that represent the proper meaning, which facilitated the consideration of the appropriateness of category naming.

The patients’ attributes are summarized in Table 1. Their mean age ± standard deviation was 37.9 ± 5.2 years (range 25 - 56). The length of fertility treatment was 1 year and 4 months. The patients noted that the primary cause of their infertility (43.3%) was unclear, and the secondary cause (10.3%) was male factors. The treatment for 20.9% of the patients was assisted reproductive technology. Of these patients, 7.8% had a significant medical history and 29.9% had experienced changing hospitals.

*ART = assisted reproductive technology.

The factor structure was confirmed for each variable in the care needs measurement. Factor analysis was performed using the alpha factor for the factor extraction method and the Varimax rotation methods. The 4 subscales were extracted using 15 items. The results of the factor analysis yielded factor loadings of 0.30 or more for all items, and the cumulative contribution rate was 40.3%. The reliability of the questionnaires was established using the total (0.80) and individual Cronbach’s alpha coefficient of 0.66 - 0.71.

The most common answers regarding the care needs of male patients were warm support for their wives (69.2%). Specifically, the care needs of male patients included provisions of various kinds of information such as treatment approaches (63.2%), daily life information for conceiving (61.7%), support for their wives (60.1%), information on examination data (56.1%), and support for their wives to alleviate their burden (50.5%). The results are shown in Figure 1.

Next, the presence or absence of care needs of male patients were examined between 2 groups according to their attributes using the chi-squared test. The “changing hospital experience group” significantly needed more information on the wife’s burden than the “without changing hospital experience group” (X² = 4.3, p < 0.05) (Figure 2). The “significant medical history group” needed a counselor introduction more than the “nonsignificant medical history group” (X² = 5.6, p < 0.05) (Figure 3). The “significant medical history group” needed a self-help group introduction more than the “nonsignificant medical history group” (X² = 7.3, p < 0.01).The “with male factors group” significantly needed a gentle polite correspondence more than the “without male factors group” (X² = 5.2, p < 0.05) (Figure 4). In addition, the “male factors group” significantly needed a warm support for their wives more than the “without male factors group” (X² = 4.2, p < 0.05) (Figure 5). The “male and female factors group” significantly needed daily life information for conceiving more than the “without male and female factors group” was (X² = 6.0, p < 0.05) (Figure 6).

The results of the content analysis of the open-ended responses revealed 6 categories as follows: 1) warm care, 2) improvement of examination environment, 3) adjustment of medical examination schedule, 4) information provision 5) support for wife, and 6) subsidy for treatment costs. Comments included requests

and suggestions for future improvements (Table 2). Because the questions were open-ended, not all of the respondents answered the questions and only 44 respondents were obtained.

Male patients undergoing infertility treatment have significantly lower incidence of severe depressive symptoms, personal distress, and social distress [12] as well as depression than female patients [13]. In the present study, the male patients had different care needs depending on the male factors and significant medical history. Therefore, it is equally necessary to exert effort in providing warm care to male patients after their background assessment. The specific contents of warm care identified in the present study were as follows: 1) an atmosphere wherein questions can be easily asked; 2) strict but very polite consultations; 3) empathetic listening; 4) information sharing among medical staff; and 5) sympathetic support.

The necessity of information provision and the importance of patient-centered involvement were previously recognized. In particular, information provision, respect for a patient’s values, continuity of care, and team competence were found to be directly associated with higher intentions of patients to comply with treatment [14]. Information provision and continuity of care were also shown to be indirectly associated with better individual well-being [15]. As the therapy content has become more specific, infertility treatment methods have also continually evolved. Thus, providing information to patients is absolutely essential. Most female infertility patients requested additional information related to infertility [16]. These included the following items: causes of infertility, how to conceive, and how to improve fertility. On the other hand, the care needs of male infertility patients were provisions of information. These included the following items: treatment approaches, daily life information for conceiving, support for their wives, information on examination data, and support for their wives to alleviate their burden (Figure 1). The difference between the male and female infertility patients was that the female infertility patients were mainly concerned with their own care and information collection. The male infertility patients needed information not only for themselves but also for their female partners. It was suggested that infertile men treated their female partners with respect.

It is important for medical professionals involved in infertility treatment to provide support not for a single patient alone but for the couple. Nonetheless, it is evident from this study that men needed more supportive care than their wives. This is because infertile men have less opportunity to visit the clinic and less chance of nursing staff involvement. Thus, identification of the specific care needs of male patients in this research may provide more information on how to provide them with optimal treatment and follow-up support.

There were some limitations in this study. First, since the survey was conducted at 4 fertility specialized facilities in the metropolitan area, there may be differences in the care needs of patients based on their local cities. Second, convenience sampling was used with the responses of a small number of participants (n = 321) analyzed; thus, this study was not a large-scale investigation. The opinions of only 44 respondents to the open-ended questions were analyzed, which may not completely reflect the opinions of all the participants. Third, the cross-sectional design of the study does not allow for cause and effect analysis between the study variables. Because of this study design, the findings only showed an association between the attitude of an individual and the care needs at a single point in time. In the future, it will be necessary to intervene to meet these care needs, as well as to consider how the high degree of satisfaction affects the psychological state of a patient under treatment and the treatment outcome.