Vergelijkend onderzoek naar het effect van een meervoudige strategie op het gebruik van voorspellende modellen en afwachtend beleid bij paren met vruchtbaarheidsproblemen.

Rationale:

Prognostic models in reproductive medicine can help to identify subfertile couples that would benefit from fertility treatment. An expectant management in couples with a good chance of a natural conception prevents unnecessary treatment and is recommended in the ‘national network guideline subfertility’ of NVOG and NHG. However, actual implementation is not optimal, leaving a strong potential for improvement. In preparation of the present study, we have performed qualitative and quantitative studies among subfertile couples and professionals, in which we have identified several barriers and facilitators of tailored expectant management (TEM). The results of these studies have been used to develop an implementation strategy.



Objective:

The main goal is to investigate how an increase in the implementation of tailored expectant management in Dutch fertility care can be best achieved. In this study we want to determine the effects of a multifaceted implementation strategy compared to usual care (no strategy) with regard to the number couples with a good prognosis suitable for tailored expectant management.



Study design:

In a cluster randomized trial, 25 clinics and their allied general practitioner units will participate. The clinics and their allied general practitioners will be divided in six regions. Randomisation will be stratified for region. There will be randomised between the multifaceted implementation strategy versus usual care The strategy will be implemented for a period of one year. The effect of the strategy will be evaluated by a pre- and post-randomization data collection and a process evaluation.



Study population:

Couples in primary and secondary care with unexplained subfertility with a good prognosis (>30%) for natural conception within one year based on the prediction model of Hunault.
Professionals who provide care for these couples such as general practitioners, fertility doctors and gynaecologists.



Intervention:

The multifaceted implementation strategy, developed based on the prior barrier and facilitator analysis, will focus on 3 levels:

1. Patient-level: Education materials;

2. Professionals-level: Audit and feedback, educational outreach visits, communication training and a digital version of the prognostic model as an application for a smartphone;

3. Organisation-level: Local protocol and a local consensus processes.



Main study parameters/endpoints:

The primary outcome will be adherence of tailored expectant management measured by percentage of couples with a good prognosis and a tailored expectant management.

Secondary outcomes: treatment outcome related measures, process related measures, patient related measures.

The aim of this study is to investigate how an increase in the implementation of tailored expectant management in Dutch fertility care can be best achieved. In this study we want to determine the effects of a multifaceted implementation strategy compared to usual care (no strategy) with regard to the number of couples with a good prognosis suitable for tailored expectant management.

The preparation will take 3 months. A pre-randomization data collection will be performed in all participating clinics, this data will be abstracted from medical records and questionnaires. This will take 4 months. The multifaceted strategy will be implemented for a period of nine to twelve months. During this period patients will be treated according to the local protocol. The after measurement will take 3 months and a process evaluation is also performed after the intervention period. The total duration of the study will be two years.

In this cluster randomized trial, 25 clinics and their allied general practitioner units are randomized between the intervention and control group. In the intervention group a multifaceted implementation strategy will be implemented for a period of one year while the control group provides care as usual.

The multifaceted implementation strategy is developed based on the prior barrier and facilitator analysis. The strategy aims to improve the patients’ knowledge and create realistic expectations of treatment and possible benefits and harms, improving communication and counseling skills of the professionals and improving continuity of care. Therefore the implementation strategy will focus on 3 levels:

1. Patient-level: Education material in the form of leaflets, online information and a smartphone App;

2. Professionals-level: Audit and feedback of pre-randomisation data collection, educational outreach visits, communication training and a digital version of the prognostic model as an application for a smartphone;

3. Organisation-level: Local protocol and a local consensus processes.

The effect of the strategy will be evaluated by a pre- and post-randomization data collection and a process evaluation.