title: Overtreatment in couples with unexplained infertility.
abstract: OBJECTIVE
  What is the percentage of overtreatment, i.e. fertility treatment started too early, in couples with unexplained infertility who were eligible for tailored expectant management?
  
  
  CONCLUSIONS
  Overtreatment occurred in 36% of couples with unexplained infertility who were eligible for an expectant management of at least 6 months.
  
  
  BACKGROUND
  Prognostic models in reproductive medicine can help to identify infertile couples that would benefit from fertility treatment. In couples with unexplained infertility with a good chance of natural conception within 1 year, based on the Hunault prediction model, an expectant management of 6-12 months, as recommended in international fertility guidelines, prevents unnecessary treatment.
  
  
  METHODS
  A retrospective cohort study in 25 participating clinics, with follow-up of all couples who were seen for infertility in 2011-2012.
  
  
  METHODS
  In all, 9818 couples were seen for infertility in the participating clinics. Couples were eligible to participate if they were diagnosed with unexplained infertility and had a good prognosis of natural conception (>30%) within 1 year based on the Hunault prediction model. Data to assess overtreatment were collected from medical records. Multilevel regression analyses were performed to investigate associations of overtreatment with patient and clinic characteristics.
  
  
  RESULTS
  Five hundred and forty-four couples eligible for expectant management were included in this study. Among these, overtreatment, i.e. starting medically assisted reproduction within 6 months, occurred in 36%. The underlying quality indicators showed that in 34% no prognosis was calculated and that in 42% expectant management was not recommended. Finally, 16% of the couples for whom a correct recommendation of expectant management for at least 6 months was made, started treatment within 6 months anyway. Overtreatment was associated with childlessness, higher female age and a longer duration of infertility. No associations between overtreatment and clinic characteristics were found.
  
  
  CONCLUSIONS
  The response rate was low compared with other fertility studies. Evaluation of possible selection bias showed that responders had a higher socio-economic status than non-responders.
  
  
  CONCLUSIONS
  Our findings show that developing and publishing guideline recommendations on tailored expectant management (TEM) is not enough and that overtreatment still occurs frequently. Future research should focus on tailored efforts to implement guideline recommendations on TEM.
  
  
  BACKGROUND
  Supported by Netherlands Organisation for Health Research and Development (ZonMW). ZonMW had no role in designing the study, data collection, analysis and interpretation of data or writing of the report. Competing interests: none.
  
  
  BACKGROUND
  www.trialregister.nl NTR3405.
authors.affiliation: Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, Nijmegen 6500 HB, The Netherlands.
authors.forename: F A M
authors.initials: FA
authors.lastname: Kersten
authors.affiliation: Scientific Institute for Quality of Healthcare, Radboud University Medical Center, PO Box 9101, Nijmegen 6500 HB, The Netherlands.
authors.forename: R P G M
authors.initials: RP
authors.lastname: Hermens
authors.affiliation: Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, Nijmegen 6500 HB, The Netherlands.
authors.forename: D D M
authors.initials: DD
authors.lastname: Braat
authors.affiliation: Department of Obstetrics and Gynaecology, University Medical Center Groningen, University of Groningen, PO Box 30.001, Groningen 9700 RB, The Netherlands.
authors.forename: A
authors.initials: A
authors.lastname: Hoek
authors.affiliation: The Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide, 5005 SA Adelaide, Australia.
authors.forename: B W J
authors.initials: BW
authors.lastname: Mol
authors.affiliation: Centre for Reproductive Medicine, Academic Medical Centre, PO Box 22660, 1100 DD Amsterdam, The Netherlands.
authors.forename: M
authors.initials: M
authors.lastname: Goddijn
authors.affiliation: Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, Nijmegen 6500 HB, The Netherlands willianne.nelen@radboudumc.nl.
authors.forename: W L D M
authors.initials: WL
authors.lastname: Nelen
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D007246:Infertility / Q000628:therapy*; D008297:Male; D008962:Models, Theoretical; D011247:Pregnancy; D011256:Pregnancy Outcome; D027724:Reproductive Techniques, Assisted / Q000706:statistics & numerical data*; D013997:Time Factors
keywords: expectant management; guideline adherence; implementation; prognostic models; unexplained infertility