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Mahabamunuge J, Seifer DB. Moving toward Narrowing the United States Gap in Assisted Reproductive Technology (ART) Racial and Ethnic Disparities in the Next Decade. J Clin Med 2024; 13:2224. [PMID: 38673497 PMCID: PMC11050514 DOI: 10.3390/jcm13082224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 03/25/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024] Open
Abstract
The Disparities in Assisted Reproductive Technology (DART) hypothesis, initially described in 2013 and further modified in 2022, is a conceptual framework to examine the scope and depth of underlying contributing factors to the differences in access and treatment outcomes for racial and ethnic minorities undergoing ART in the United States. In 2009, the World Health Organization defined infertility as a disease of the reproductive system, thus recognizing it as a medical problem warranting treatment. Now, infertility care is largely recognized as a human right. However, disparities in Reproductive Endocrinology and Infertility (REI) care in the US persist today. While several studies and review articles have suggested possible solutions to racial and ethnic disparities in access and outcomes in ART, few have accounted for and addressed the multiple complex factors contributing to these disparities on a systemic level. This review aims to acknowledge and address the myriad of contributing factors through the DART hypothesis which converge in racial/ethnic disparities in ART and considers possible solutions to effect large scale societal change by narrowing these gaps within the next decade.
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Affiliation(s)
- Jasmin Mahabamunuge
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA;
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Lee IT, Berger DS, Koelper N, Senapati S, Mainigi M. Race, ovarian responsiveness, and live birth after in vitro fertilization. Fertil Steril 2023; 120:1023-1032. [PMID: 37549835 DOI: 10.1016/j.fertnstert.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVE To determine if ovarian responsiveness to gonadotropin stimulation differs by race/ethnicity and whether this predicts live birth rates (LBRs) in non-White patients undergoing in vitro fertilization (IVF). DESIGN Retrospective cohort study. SETTING Academic infertility center. PATIENT(S) White, Asian, Black, and Hispanic patients undergoing ovarian stimulation for IVF. INTERVENTION(S) Self-reported race and ethnicity. MAIN OUTCOME MEASURE(S) The primary outcome was ovarian sensitivity index (OSI), defined as (the number of oocytes retrieved ÷ total gonadotropin dose) × 1,000 as a measure of ovarian responsiveness, adjusting for age, body mass index, infertility diagnosis, and cycle number. Secondary outcomes included live birth and clinical pregnancy after first retrievals, adjusting for age, infertility diagnosis, and history of fibroids, as well as miscarriage rate per clinical pregnancy, adjusting for age, body mass index, infertility diagnosis, duration of infertility, history of fibroids, and use of preimplantation genetic testing for aneuploidy. RESULT(S) The primary analysis of OSI included 3,360 (70.2%) retrievals from White patients, 704 (14.7%) retrievals from Asian patients, 553 (11.6%) retrievals from Black patients, and 168 (3.5%) retrievals from Hispanic patients. Black and Hispanic patients had higher OSIs than White patients after accounting for those with multiple retrievals and adjusting for confounders (6.08 in Black and 6.27 in Hispanic, compared with 5.25 in White). There was no difference in OSI between Asian and White patients. The pregnancy outcomes analyses included 2,299 retrievals. Despite greater ovarian responsiveness, Black and Hispanic patients had lower LBRs compared with White patients, although these differences were not statistically significant after adjusting for confounders (adjusted odds ratio, 0.83; 95% confidence interval [CI], 0.63-1.09, for Black; adjusted odds ratio, 0.93; 95% CI, 0.61-1.43, for Hispanic). Ovarian sensitivity index was modestly predictive of live birth in White and Asian patients but not in Black (area under the curve, 0.51; 95% CI, 0.38-0.64) and Hispanic (area under the curve, 0.50; 95% CI, 0.37-0.63) patients. CONCLUSION(S) Black and Hispanic patients have higher ovarian responsiveness to stimulation during IVF but do not experience a consequent increase in LBR. Factors beyond differences in responsiveness to ovarian stimulation need to be explored to address the racial/ethnic disparity established in prior literature.
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Affiliation(s)
- Iris T Lee
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Dara S Berger
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nathanael Koelper
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Suneeta Senapati
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Monica Mainigi
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
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Weiss MS, Marsh EE. Navigating Unequal Paths: Racial Disparities in the Infertility Journey. Obstet Gynecol 2023; 142:940-947. [PMID: 37678890 PMCID: PMC10510808 DOI: 10.1097/aog.0000000000005354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 06/30/2023] [Accepted: 07/06/2023] [Indexed: 09/09/2023]
Abstract
Infertility is one of the most emotionally devastating conditions experienced during the reproductive window. Although not life-threatening, it significantly erodes quality of life for those with the diagnosis. Disturbingly, data demonstrate the existence of profound racial disparities that persist along the entire journey of infertility. Though most of the scientific literature emphasizes disparities in clinical outcomes after infertility treatment, it is important to recognize that these inequities are the downstream effect of a series of distinct challenges encountered by historically marginalized people on their path to parenthood. In this review, we explore the current state of knowledge concerning the inequities at each "step" in the path to overcome infertility challenges and propose solutions to create a future in which reproductive medicine is truly equitable, accessible, and supportive for everyone.
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Affiliation(s)
- Marissa Steinberg Weiss
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania; and the Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
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Huddleston A, Ray K, Bacani R, Staggs J, Anderson RM, Vassar M. Inequities in Medically Assisted Reproduction: a Scoping Review. Reprod Sci 2023:10.1007/s43032-023-01236-6. [PMID: 37099229 PMCID: PMC10132432 DOI: 10.1007/s43032-023-01236-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 03/31/2023] [Indexed: 04/27/2023]
Abstract
Infertility has a high prevalence in the USA and health inequities play a large role in access to medically assisted reproduction (MAR). The aim of this study was to identify gaps in research pertaining to inequities in MAR and propose suggestions for future research directions. Searches were performed using MEDLINE and Ovid Embase. Articles that reported on MAR inequities, published between 2016 and 2021 in the USA, and written in English were included. The inequities investigated were adapted from the NIH-designated health disparities populations. Each article's inequity findings were extracted and reported, along with frequencies of inequities. Our sample included 66 studies. The majority of the studies investigated MAR outcomes by race/ethnicity and found that historically marginalized populations had poorer outcomes. LGBTQ + populations were less likely to use MAR or seek infertility care. Most studies found positive correlations with MAR use with income and education. The least commonly studied inequities in our sample were sex and/or gender and rural/under-resourced populations; findings showed that men and people from rural/under-resourced populations were less likely to access MAR. Studies that examined occupational status had varying findings. We suggest that future research be targeted toward: (1) standardizing and diversifying race/ethnicity reporting regarding MAR, (2) the use of community-based participatory research to increase data for LGBTQ + patients, and (3) increasing access to infertility care for men.
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Affiliation(s)
- Abbi Huddleston
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, 1111 W 17Th St, Tulsa, OK, 74107, USA.
| | - Kaylin Ray
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, 1111 W 17Th St, Tulsa, OK, 74107, USA
| | - Rigel Bacani
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, 1111 W 17Th St, Tulsa, OK, 74107, USA
| | - Jordan Staggs
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, 1111 W 17Th St, Tulsa, OK, 74107, USA
| | - Reece M Anderson
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, 1111 W 17Th St, Tulsa, OK, 74107, USA
| | - Matt Vassar
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, 1111 W 17Th St, Tulsa, OK, 74107, USA
- Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
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Racial and ethnic disparities in assisted reproductive technology: a systematic review. Fertil Steril 2023; 119:341-347. [PMID: 36682687 DOI: 10.1016/j.fertnstert.2023.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023]
Abstract
There is emergent scientific literature examining the disparities in reproductive care of women in the United States. Reproduction is a basic human right and there are unique challenges that racial and ethnic minorities face in accessing fertility care and assisted reproductive technology. The identification of these disparities can aid in identifying areas for interventions to improve and resolve, the inequities that exist in providing care for minority populations. A literature search was performed using PubMed to identify articles with data specific to racial and ethnic differences in study populations as it related to infertility, access to care, and treatment outcomes. The following review and collection of articles provide a comprehensive overview of the disparities that exist, the factors that contribute to these disparities, and recommendations for how providers and health care systems may begin to resolve the gaps in equitable care.
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[Impact of geographical origin on IVF results: A monocentric observational French cohort study comparing 3 populations: Europe, Maghreb and Sub-Saharan Africa]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2023; 51:157-165. [PMID: 36529380 DOI: 10.1016/j.gofs.2022.11.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/24/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Many studies in the literature have found an association between geographic origin and poorer IVF outcomes in African American and Asian minority populations compared with Caucasian populations. The limitations of these studies are multiple (inconsistencies in the characterization of ethnic groups, mostly multicenter studies with large variability in success rates between centers, minorities having more limited and delayed access to care). Thus, socioeconomic status may have been an important bias in judging environmental or "genetic" factors. The objective of our study is to determine whether geographic origin would influence IVF response and outcomes in a French university hospital center with equal access to care. MATERIAL AND METHODS This was a retrospective single-center observational study from January 2013 to January 2020 comparing IVF response in 3 populations of similar size at our Medically Assisted Reproduction center, with all charges covered by Medicare. The primary objective was ovarian response to IVF, and the secondary objectives were clinical pregnancy rate and live birth rate per cycle started. RESULTS We analyzed 1669 cycles of first IVF attempt in women from Europe (525), Sub-Saharan Africa (649) and Maghreb (495). The SSA and Maghrebi women had a higher BMI. SSA women were more often affected by tubal or uterine infertility, HIV or HBV infection, and were less often nulliparous. The indication of male infertility was more frequent in Maghrebi women with a higher ICSI rate. There was no significant difference in the duration of stimulation, endometrial thickness at induction, number of oocytes collected, fertilization rate, number of embryos transferred and frozen. Nevertheless, the cancellation rate was higher in SSA and Maghrebi women and the total dose of gonadotropins was higher in SSA. No significant difference was found between Maghrebi and European women on IVF outcomes except for a lower number of total embryos in Maghrebi women (3.33 vs. 4.13 on average, P<0.001). The SSA had a lower rate of mature oocytes per puncture (66 % vs. 73 %, P<0.001), a lower number of total embryos per puncture (3.56 vs. 4.13 on average, P<0.016), a lower rate of clinical pregnancies per cycle (11.7% vs. 20.4%, P<0.001), a lower rate of live births per cycle (6.9% vs. 15.2%, P<0.001). CONCLUSION There was no significant difference between European and Maghrebi women at the end of IVF, but the results were lower for those from SSA.
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Tang H, Yang M, Yi H, Lin M. Risk Factors of Preterm Birth and Low Birth Weight in Singletons Conceived Through Frozen Embryo Transfer: A Retrospective Study. Int J Gen Med 2022; 15:8693-8704. [PMID: 36575734 PMCID: PMC9790167 DOI: 10.2147/ijgm.s394231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Background The risks of adverse perinatal outcomes in offspring conceived following frozen-thawed embryo transfer (FET) assisted reproductive technology (ART) are inconsistent. The aim of this study was to analyze the risk factors for preterm birth and low birth weight in singletons after FET. Methods 386 FET cycles was conducted at the Reproductive Medicine Center of Meizhou People's Hospital. The relationship between clinical characteristics and outcomes (term birth and preterm birth, normal birth weight and low birth weight) was analyzed. Results The rate of primary infertility, basal FSH and T levels, gestational age, birth weight, and proportion of male fetuses were significantly different in the preterm and full-term groups. Logistic regression analysis showed that high maternal age (≥35 years) (OR 3.652, 95% CI: 1.683-7.925, P=0.001), primary infertility (OR 2.869, 95% CI: 1.461-5.632, P=0.002), low FSH level (<6.215 mIU/mL) (OR 3.272, 95% CI: 1.743-6.144, P<0.001), and hormone replacement therapy (HRT) method (OR 2.780, 95% CI: 1.088-7.100, P=0.033) may increase risk of preterm birth after FET. Gestational age and birth weight were significantly different in fetuses with low birth weight (<2500g, n=38) and normal birth weight (≥2500g and <4000g, n=333). Logistic regression analysis showed that low basal FSH level (<6.215 mIU/mL) (OR 0.425, 95% CI: 0.209-0.865, P=0.018), and HRT method of endometrial preparation for FET (OR 0.272, 95% CI: 0.079-0.934, P=0.039) may reduce the risk of low birth weight after FET. Conclusion High maternal age, primary infertility, low FSH level, HRT method of endometrial preparation for FET, and male fetus may increase risk of preterm birth after FET. In addition, primary infertility, low basal FSH level, and HRT method of endometrial preparation may reduce the risk of low birth weight after FET.
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Affiliation(s)
- Haiyu Tang
- Reproductive Medicine Center, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China,Guangdong Provincial Key Laboratory of Precision Medicine and Clinical Translational Research of Hakka Population, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China,Correspondence: Haiyu Tang, Reproductive Medicine Center, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, No. 63 Huang tang Road, Meijiang District, Meizhou, People’s Republic of China, Tel +86 753-2131-883, Email
| | - Man Yang
- Reproductive Medicine Center, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China,Guangdong Provincial Key Laboratory of Precision Medicine and Clinical Translational Research of Hakka Population, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China
| | - Honggan Yi
- Reproductive Medicine Center, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China,Guangdong Provincial Key Laboratory of Precision Medicine and Clinical Translational Research of Hakka Population, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China
| | - Mei Lin
- Reproductive Medicine Center, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China,Guangdong Provincial Key Laboratory of Precision Medicine and Clinical Translational Research of Hakka Population, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China
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Brodeur TY, Grow D, Esfandiari N. Access to Fertility Care in Geographically Underserved Populations, a Second Look. Reprod Sci 2022; 29:1983-1987. [PMID: 35680726 PMCID: PMC9181892 DOI: 10.1007/s43032-022-00991-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 05/29/2022] [Indexed: 11/30/2022]
Abstract
Infertility has a prevalence of up to 16% worldwide and is on the rise in developed nations, largely due to pursuing childbearing at advanced reproductive ages. Advances in assisted reproductive technology have benefitted socioeconomically advantaged patients disproportionately. High costs of fertility care are largely responsible for this disparity; however, patients in rural areas also face barriers in accessing both gynecology and reproductive endocrinology subspecialty care. Here, focusing on the USA, we discuss fertility care in geographically underserved areas and low-resource settings, and the impact on reproductive outcomes. Increased innovation to improve patient access to fertility care such as assisted reproductive technology is critical for ensuring equity. Remote monitoring is frequently performed by fertility centers, but partnership with local gynecologists has also been demonstrated to be an effective assisted reproductive technology monitoring method. Telehealth is now in mainstream use and the continued application to reduce geographic barriers to infertility patients is imperative. Partnership between local gynecologists and reproductive endocrinology and infertility specialists may improve patient access to fertility care and provide the unique benefits of continuity and ongoing local social support.
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Affiliation(s)
- Tia Y Brodeur
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology and Reproductive Sciences, University of Vermont, 111 Colchester Avenue, Burlington, VT, 05401, USA
| | - Daniel Grow
- The Center for Advanced Reproductive Services, Department of Obstetrics and Gynecology, University of Connecticut, Farmington, CT, USA
| | - Navid Esfandiari
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology and Reproductive Sciences, University of Vermont, 111 Colchester Avenue, Burlington, VT, 05401, USA.
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