1. Over a third of couples eligible for expectant management of unexplained fertility were treated; prognosis was often not calculated and/or expectant management was frequently not recommended.
2. Couples who were expectantly managed had comparable pregnancy rates to those who were overtreated.
Evidence Rating Level: 2 (Good)
Study Rundown: The use of assisted reproductive technology (ART) is becoming increasingly common and contributes a significant cost to healthcare expenditures. Unexplained infertility is defined as infertility despite documented adequate ovarian reserve, tubal patency as well as normal uterine anatomy, semen analysis and ovulatory cycles, but the initial treatment of choice is unclear. In the U.S., while no clear evidence-based guildelines exist to guide practice, common practice is to start with low-resource interventions, such as timed intercourse, and to only utilize higher resource interventions, such as clomid-IUI cycles (clomiphene citrate and intrauterine insemination), in a step-wise fashion. In contrast, the Netherlands has specific guidelines for tailored expectant management (TEM), including diagnosis using the Hunault prognostic model, recommending TEM for 6-12 months where appropriate, and adhering to this recommendation. Prior studies suggest that when the chance of spontaneous pregnancy is >30%, fertility treatment increases cost without improvement in the likelihood of successful pregnancy compared to expectant management (regular intercourse or timed intercourse just prior to ovulation) for 6-12 months. The present work is the first to explore both the incidence of overtreatment and the forces that motivate it. The authors found that overtreatment occurred more than one-third of the time, in many cases without evaluation of prognosis and/or recommendation for TEM, and that this did not increase the likelihood of pregnancy.
Limitations include high non-response rate and limited generalizability to countries that have other insurance models. A similar study in the U.S. is needed to identify whether overtreatment of unexplained infertility exists and, if so, what guidelines can be implemented to minimize medically unnecessary treatment.
In-Depth [prospective cohort study]: This study evaluated the incidence of overtreatment of couples with unexplained infertility eligible for tailored expectant management, defined as >30% likelihood of spontaneous pregnancy within 1 year, in 544 Dutch couples. Outcomes of interest included evaluation of prognosis, recommendation for expectant management, adherence to this recommendation, and pregnancy.
Overall, 36.4% of couples were overtreated and 34.2% did not receive a calculation of fecundity prognosis; 42.3% received an incorrect treatment recommendation and 16.2% who were recommended for a period of expectant management instead opted for treatment. Among couples who were overtreated, 28% were pregnant within 6 months and 42% within 1 year compared to 31% and 41%, respectively, in couples managed expectantly.
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