Role of medical practices in early drop-out in infertility care

Study questionWhat is the burden of early infertility care drop-out in the context of full reimbursement of infertility care and are medical practices associated with drop-out?Summary answerMedical practices seem associated with early infertility care drop-out whose burden remains high despite the equality of care policy in FranceWhat is known alreadyMore than half of couples drop out of their infertility treatment before pregnancy. Direct costs of infertility care are widely cited as the major barrier to continuation of care. In France, infertility treatments are fully reimbursed. Data from US IVF centres have shown a high estimated drop-out from the beginning and at each step of infertility treatment. Some studies have suggested a difference in medical practices during infertility care between couples who have dropped out and couples who have continued careStudy design, size, durationCohort study of all women aged 18–49 years who started infertility treatment between January–August 2016 in mainland France with a private practitioner and who had not been successfully treated at a 24-month follow-up.Participants/materials, setting, methodsThe cohort was based on the French national health insurance and hospital databases that exhaustively record reimbursed healthcare. Infertility treatment included ovarian induction by gonadotropin and clomifene. Outcome was infertility care drop-out within 3 months after starting treatment. Stratified analyses were performed based on the first treatment prescribed, with three categories: clomifene prescribed by a general practitioner, clomifene by a gynaecologist or gonadotropin by a gynaecologistMain results and the role of chanceAmong women unsuccessfully treated by ovarian induction, 31.1% dropped out of infertility care within 3 months. Women who started treatment with a general practitioner were more frequently socially disadvantaged (40.6%), less closely monitored (ultrasound and hormonal tests had not been done in 53.6% and 64.8%, respectively) and dropped out more frequently (46.8%). Where the prescriber of treatment was a gynaecologist, older age (35–39 and 40–43 years) was associated with higher probability of early drop-out with OR 1.5 (95% CI 1.3–1.7) and 2.2 (95% CI 1.9–2.5) for gonadotropins and 1.2 (95% CI 1.1–1.3) and 1.9 (95% CI 1.7–2.2) for clomifene. Disadvantaged social status was associated with higher early infertility care drop-out, whereas good monitoring was associated with a lower probability of early drop-out in all three categories of treatments and prescribersLimitations, reasons for cautionThese medical and administrative data did not allow us to explore medical practices in greater depth, notably the doctor-patient relationshipWider implications of the findings: This is the first estimation of early infertility care drop-out in a general population where treatment is fully reimbursed, exploring the implication of medical practices in early drop-out. Better access to good medical practices is needed for less socially advantaged people, beyond the current equality of care policy in France