Discontinuation of treatment in subfertile couples with cryopreserved embryos: a multicenter study on rates and reasons of dropout.

Study question: What is the dropout rate for couples with remaining cryo- preserved embryos and what are the reasons for postponing or discontinuing the transfer of cryopreserved embryos?
Summary answer: The dropout rate is 9.0% in patients with remaining cryopreserved embryos. Main reasons to discontinue their treatment are psy- chological/physical burden and impact on work.
What is known already: In fresh ART cycles, the physical and psychological burden associated with an ART treatment is the major reason for patients to delay or even discontinue their treatment. For IVF and ICSI, rates of discontin- uation vary in Europe from 17 to 70%. In addition, discontinuation of ART treatment may contribute to compromised cumulative pregnancy rates in ART. In case of the presence of cryopreserved embryos, delaying treatment is prob- ably less frequent given the lower burden of a natural or artificially prepared frozen embryo transfer cycle. Nevertheless, no data are available regarding rates and reasons for dropout in this population.
Study design, size, duration: This multicenter study included patients from 11 Belgian fertility centers between 2012 and 2017. Patients were considered dropouts (n = 1917) in case they underwent an unsuccessful fresh (“fresh group”) or cryo (“in between group”) embryo transfer and did not start a subsequent cryo cycle within one year.
Participants/materials, setting, methods: An online anonymous ques- tionnaire, aiming to explore the reasons for dropout, was developed, approved by all the ethical committees and sent to the eligible patients. An unsuccessful embryo transfer was defined by no pregnancy, a biochemical pregnancy, an ectopic pregnancy or a miscarriage <12 weeks. Exclusion criteria were cryo- preservation of embryos in case of preimplantation genetic testing, fertility preservation cycles and oocyte donation cycles.
Main results and the role of chance: The overall treatment dropout rate for couples with remaining cryopreserved embryos is 9.0%. The dropout rates in the “fresh” and “in between” group are 9.7% and 8.0%, respectively. The response rate for the online questionnaire was 15.8% (n = 304/1917). The most important reasons for dropout are psychological (50%) and physical (43%) bur- den, the impact on work (29%), age of the woman in treatment (25%) and the impact on relationship (25%). The decision of the couple to postpone or stop treatment is influenced by external factors in only 16% of the cases. Seventy-eight percent of respondents are satisfied with the care delivered by their fertility center, and 92% would recommend the center to peers. Out of suggested improvements to the respondents, psychological support before (41%), during (51%) and after (51%) treatment, as well as lifestyle counseling (44%) and receiv- ing digital information (43%) are most frequently selected.
Limitations, reasons for caution: As questionnaires cannot fully capture emotional responses or feelings, open answer boxes were added to the 10-point Likert scale used for some of the questions. Although the response rate is quite high compared to similar studies in the field, the results should not be extrapo- lated to the entire dropout population.
Wider implications of the findings: Based on our data, patients highly recommend enhanced psychological support throughout the entire ART treat- ment, as well as lifestyle advice and digital communication regarding information relevant for the treatment. This stresses the need to better integrate these aspects of patient centered care in our daily ART practice.