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Objective: To assess adherence to expectant management of 6-12 months in couples with unexplained subfertility, as recommended by the Dutch Networkguideline Subfertility., Design: A retrospective cohort study in 25 clinics., Method: Couples were eligible to participate if they were diagnosed with unexplained subfertility and had a good prognosis of natural conception within one year (>30%), for these couples the network guideline recommends an expectant management. Outcomes measures are overtreatment, i.e. couples that started treatment within six months, and three quality indicators: 1) prognosis not calculated, 2) no correct expectant management advised, 3) starting treatment too soon despite a correct advise. Data collection was obtained from medical records. Multilevel regression analyses were performed to investigate associations of overtreatment with patient and clinic characteristics., Results: We included 544 couples. Overtreatment occurred in 36% (N=198). In 34% (N=186) of all couples no prognosis was calculated (1), and in 42% (N=230) of all couples expectant management was not advised correctly (2). When a correct expectant management of six to twelve months was advised, 16% (N=51) started treatment too soon anyway. Overtreatment occurred more frequently in childless couples, a higher female age, and a longer duration of infertility., Conclusion: Our findings show that developing and publishing guideline recommendations on expectant management is not enough and that overtreatment still occurs frequently. To improve future care the next step is to evaluate a tailored implementation strategy to improve adherence to the recommendations on expectant management by the Dutch Networkguideline Subfertility.

The postponement of childbearing is determined by societal factors and is related to the fact that it is often difficult for women to combine an education, a job or a career with having children and taking care of a family. Especially gynaecologists are increasingly confronted with women who undergo the medical consequences of such postponement. Postponing the first pregnancy is accompanied by an increased risk of unwanted infertility. If women do succeed in becoming pregnant later in life, there is an increased risk of complications during pregnancy and delivery. The child runs a greater risk of chromosomal aberrations and of mental and physical handicaps related to increased numbers of premature births and fertility treatments. All these problems begin to increase after age 30, but especially after age 35. Finally, the risk of breast cancer is also increased if a woman delays the birth of her first child or remains childless.