# Family planning of infertile couples: a systematic review of intentions regarding parenthood and return to ART

## TL;DR

Infertile couples often do not pursue additional ART treatments for more children, despite having embryos available, due to emotional, financial, and social barriers.

## Contribution

This study systematically reviews motivations and barriers influencing family planning decisions among infertile couples, highlighting gaps in post-treatment support.

## Key findings

- Return rates to ART for a second child ranged from 25 to 50%, even when cryopreserved embryos were available.
- Factors like younger age and embryo availability were linked to higher return rates to ART.
- Emotional, financial, and social burdens were common barriers to pursuing further ART treatments.

## Abstract

What motivations and barriers influence family planning decisions among infertile individuals?

In studying the family planning of infertile couples, this review found that a significant gap persists between desired and achieved family size.

While ART has traditionally focused on live birth rate (LBR) as a primary success parameter, growing attention has been paid to whether treatments help couples achieve their desired family size. Evidence suggests that many infertile couples do not return to ART for subsequent children, despite having cryopreserved embryos available.

This review was conducted as a systematic review following PRISMA guidelines. A comprehensive search strategy was developed and implemented across PubMed and Embase databases, covering studies published in English up to May 2025. The search combined free text terms and MeSH/Emtree terms related to ‘infertility’ and ‘family planning’.

We included observational studies reporting outcomes related to family size, return to ART, or intentions for subsequent children. Two reviewers independently performed screening, data extraction, and quality assessment using the Newcastle–Ottawa Scale.

Of 2495 screened records, 9 studies were included. Across contexts, infertile couples consistently reported smaller family sizes compared to fertile ones. Return rates to ART for a second child ranged from 25 to 50%, even among those with cryopreserved embryos. Factors associated with return included younger age, availability of embryos, and previous treatment characteristics. However, emotional, financial, and social burdens often discouraged further ART use. Success rates for second ART pregnancies varied, with cumulative LBRs between 38 and 88%, depending on treatment strategy and prior history.

Scarcity of evidence and high heterogeneity across studies, including differences in design, populations, outcomes, and type of ART, may have limited comparability of the studies.

The low return rate to ART highlights unmet needs in post-treatment support and counselling. Future research should explore the psychosocial, economic, and systemic barriers that prevent couples from pursuing their reproductive goals, enabling more patient-centred care in reproductive medicine.

Open access funding was provided by Università degli Studi di Milano within the CRUI-CARE Agreement. This study was in part supported by the Italian Ministry of Health-Current Research IRCCS. E.S. reports receiving grants from Ferring and honoraria for lectures from Merck-Serono, IBSA, and Gedeon-Richter. J.D. has received consulting fees from ObsEva, Gedeon Richter, and Theramex and was a member of the scientific advisory board of ObsEva and Preglem until 2023. L.L.P. reports participation in a training course sponsored by Gedeon Richter, during which she received medical writing assistance for this paper as part of the training course. The remaining authors declare no competing interests.

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