Onderliggende mechanismen voor het zelf stopzetten van het fertiliteitstraject

Globally, one in six individuals experience infertility, defined in heterosexual couples as the inability to achieve a clinical pregnancy after at least 12 months of unprotected intercourse. An infertility diagnosis can profoundly affect emotional wellbeing. Although fertility clinics aim to support these patients, not all who begin treatment continue until achieving a live birth. Discontinuation refers to a patient's decision to stop the fertility clinic trajectory without medical advice to stop. Gaining a deeper understanding of the mechanisms underlying discontinuation across the entire clinic trajectory can help fertility clinics better support couples in achieving their ultimate goal of parenthood. First, a retrospective cohort study of 1524 couples showed that discontinuation occurs at every stage of the fertility treatment trajectory, with nearly one-third of couples discontinuing at a certain point in time. No difference was observed between first- and second-line IVF, indicating that prior IUI does not increase the likelihood of IVF discontinuation. Live birth rates were substantially higher if couples completed their treatment trajectory, increasing by a factor of 1.2 in six-cycles IUI packages and three-cycles IVF packages (first- and second-line), and by a factor of 1.3 in six-cycles IVF packages (first- and second-line). Preventing both IUI and IVF discontinuation could therefore substantially increase baby-take-home-rates. Second, the role of PROMs for personal wellbeing in identifying vulnerable patients at baseline as well as in quantifying the impact of the fertility clinic trajectory was explored across four underpowered prospective cohort studies (n=22-86 couples), that call the attention of clinicians to certain aspects of the fertility clinic trajectory. Baseline depressive and anxious reactions of both women and men seemed to help identify patients at risk of early discontinuation, making this a promising target for interventions aimed at fostering continuation. Furthermore, the overall quality of life of both partners seemed unaffected by the diagnostic workup. Finally, the emotional toll of an unsuccessful 3-cycles package of IUI should not be underestimated by fertility clinic staff as it decreased women's and men's overall quality of life and increased women's but not men's depressive reactions. Third, we tested a mechanism captured by PROMs for personal wellbeing that may foster IVF continuation. IVF is known to elicit anxiety in both women and men, peaking on the day of (especially the first) oocyte retrieval and anxiety had been identified as a predictor of discontinuation after a first failed IVF cycle. Therefore, we aimed to decrease anxiety on the day of the first oocyte retrieval by providing preparatory procedural information in a modern video format detailing the patient journey on that day, inspired by studies from the field of cardiology. Our trial randomized 190 couples about to start their first IVF cycle between the standard of care or the standard of care supplemented with the video. The intervention significantly reduced men's anxiety on the day of oocyte retrieval but had no effect on the primary outcome, women's anxiety. Surprisingly, infertility-specific distress was higher among both women and men who watched the video despite all except one participant in the intervention group recommending the video to 99 friends or family undergoing IVF. Following the RCT, 35 additional couples participated in a qualitative process evaluation, which clarified that watching the video did not increase overall procedural knowledge but that some participants found the visualized invasive procedural steps more confronting than the earlier received abstract written and verbal information. Following couples up showed that the reduction in men's anxiety did not translate into lower IVF discontinuation. In conclusion, our findings demonstrate that couples discontinue at every stage of the fertility clinic<br />trajectory. The IUI stage of the fertility clinic trajectory should not be underestimated, given its negative impact on women's anxious reactions and both partners overall quality of life. Preventing burden and discontinuation has the potential to increase the number of completed treatment cycles, thereby improving live birth rates. Our attempts to decrease anxiety with procedural IVF information were effective in men but not in women and came at the expense of increased infertility-specific distress, potentially due to the video format of our intervention visualising invasive procedures. Baseline depressive reactions emerged as another promising focus for future interventions aimed at reducing discontinuation in both IUI and IVF treatment. Overall, these findings emphasize the importance of studying the psychological burden caused by all stages of the entire fertility clinic trajectory and of developing strategies to reduce discontinuation and ultimately improve patient outcomes.