Time to pregnancy as a correlate of fecundity: differential persistence in trying to become pregnant as a source of bias

Background Subfecundity is a frequent and often serious problem and it is important to identify its preventable determinants and to monitor fecundity over time. Since follow-up studies are difficult and expensive to conduct, time to pregnancy (TTP) in pregnant women is often used as a surrogate measure of fecundity. TTP data can be retrieved at low costs and they need no valid population registry as a source for sampling. While TTP may serve as a valid surrogate measure in many situations, its validity rests upon a number of assumptions. We have analysed one of these overlooked assumptions, the importance of persistence in trying to become pregnant. Methods By means of computer simulations we estimated bias caused by differences in persistence in pregnancy attempts. We investigated whether the assumptions made in the simulation were realistic by using empirical data from a European study. Results The mean waiting time to pregnancy and other estimates of subfecundity (or infertility) strongly depend upon the persistence of couples in pursuing a pregnancy. We show that even moderate changes in the planning behaviour considerably modify the waiting rime distribution. Empirical data confirm that persistence in trying to become pregnant is age-related. Conclusions Persistence in pregnancy attempts affects outcome measures of subfecundity in studies based upon TTP in pregnant women. It is likely that the length of time during which couples keep trying to become pregnant is influenced by a number of factors which would probably change over time or be different between populations to be compared.