Long-term outcome in couples with unexplained subfertility and an intermediate prognosis initially randomized between expectant management and immediate treatment

Inge M. Custers, Minouche M. E. van Rumste, Jan Willem van der Steeg, Madelon van Wely, Peter G. A. Hompes, Patrick Bossuyt, Frank J. Broekmans, Cees N. M. Renckens, Marinus J. C. Eijkemans, Thierry J. H. M. van Dessel, Fulco van der Veen, Ben W. J. Mol, Pieternel Steures

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BACKGROUND: We recently reported that treatment with intrauterine insemination and controlled ovarian stimulation (IUI-COS) did not increase ongoing pregnancy rates compared with expectant management (EM) in couples with unexplained subfertility and intermediate prognosis of natural conception. Long-term cost-effectiveness of a policy of initial EM is unknown. We investigated whether the recommendation not to treat during the first 6 months is valid, regarding the long-term effectiveness and cumulative costs. METHODS: Couples with unexplained subfertility and intermediate prognosis of natural conception (n = 253, at 26 public clinics, the Netherlands) were randomly allocated to 6 months EM or immediate start with IUI-COS. The couples were then treated according to local protocol, usually IUI-COS followed by IVF. We followed couples until 3 years after randomization and registered pregnancies and resources used. Primary outcome was time to ongoing pregnancy. Secondary outcome was treatment costs. Analysis was by intention-to-treat. Economic evaluation was performed from the perspective of the health care institution. RESULTS: Time to ongoing pregnancy did not differ between groups (log-rank test P = 0.98). Cumulative ongoing pregnancy rates were 72-73% for EM and IUI-COS groups, respectively relative risk 0.99 (95% confidence interval (CI) 0.85-1.1)]. Estimated mean costs per couple were (sic)3424 (95% CI (sic)880-(sic)5968) in the EM group and (sic)6040 (95% CI (sic)4055-(sic)8125) in the IUI-COS group resulting in an estimated saving of (sic)2616 per couple (95% CI (sic)385-(sic)4847) in favour of EM. CONCLUSIONS: In couples with unexplained subfertility and an intermediate prognosis of natural conception, initial EM for 6 months results in a considerable cost-saving with no delay in achieving pregnancy or jeopardizing the chance of pregnancy. Further comparisons between aggressive and milder forms of ovarian stimulation should be performed
Original languageEnglish
Pages (from-to)444-450
JournalHuman reproduction (Oxford, England)
Issue number2
Publication statusPublished - 2012

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