When and why do subfertile couples discontinue their fertility care? A longitudinal cohort study in a secondary care subfertility population

BACKGROUND: A substantial number of subfertile couples discontinues fertility care before achieving pregnancy. Most studies on dropouts are related to IVF. The aim here is to examine dropout rates at all stages of fertility care. METHODS: We analysed a consecutive cohort of 1391 couples, referred to our secondary care hospital between January 2002 and December 2006. Discontinuation rates were studied at six stages. Stage I: immediately after first visit, Stage II: during diagnostic workup, Stage III: after finishing diagnostic workup but before treatment, Stage IV: during or after non-IVF treatment, Stage V: during IVF, Stage VI: after at least 3 cycles of IVF. Reasons to discontinue and spontaneous pregnancy rates after discontinuation were secondary outcomes. RESULTS: In our cohort 319 couples dropped out of fertility care, 76.8%, 95% confidence interval (CI): 72.2-81.4 on their own initiative and 23.2% (95% CI: 18.6-27.8) on doctor's advice. Percentage (95% CI) of couples discontinuing per stage were: Stage I 6.0% (3.4-8.6), Stage II 3.4% (1.5-5.5), Stage III 35.7% (30.5-41.0), Stage IV 23.5% (18.9-28.2), Stage V 17.9% (13.7-22.1) and Stage VI 13.5% (9.7-17.2). Main reasons for dropout (%, 95% CI) were 'emotional distress' (22.3%, 17.7-26.8), 'poor prognosis' (18.8%, 14.5-23.1) and 'reject treatment' (17.2%, 13.1-21.4). The spontaneous ongoing pregnancy rate after discontinuation was 10% (6.7-13.3). CONCLUSION: About half of the couples stopped before any fertility treatment was started and one-third stopped after at least one IVF cycle. The main reasons for withdrawal were emotional distress and poor prognosis. This insight may help to improve quality of patient care by making care more responsive to the needs and expectations of subfertile couples.