Socioeconomic and racial disparities among infertility patients seeking care

Socioeconomic and Racial/Ethnic Inequalities in Infertility Prevalence, Help-Seeking, and Help Received Since 1995

BACKGROUND

In the United States, infertility and treatment for infertility are marked by racial/ethnic and socioeconomic inequalities. Simultaneously, biomedical advances and increased public health attention toward preventing and addressing infertility have grown. It is not known, however, whether the racial/ethnic and socioeconomic inequalities observed in infertility prevalence, help-seeking, or help received have changed over time.

METHODS

Using National Survey of Family Growth data (1995 through 2017-2019 cycles), this study applied multivariable logistic regression with interaction terms to investigate whether and how racial/ethnic and socioeconomic inequalities in 1) the prevalence of infertility, 2) ever seeking help to become pregnant, and 3) use of common types of medical help (advice, testing, medication for ovulation, surgery for blocked tubes, and artificial insemination) have changed over time.

RESULTS

The results showed persisting, rather than narrowing or increasing, inequalities in the prevalence of infertility and help-seeking overall. The results showed persisting racial/ethnic inequalities in testing, ovulation medication use, and surgery for blocked tubes. By contrast, the results showed widening socioeconomic inequalities in testing and narrowing inequalities in the use of ovulation medications.

CONCLUSIONS

There is little evidence to suggest policy interventions, biomedical advances, or increased public health awareness has narrowed inequalities in infertility prevalence, treatment seeking, or use of specific treatments.

Neighborhood deprivation and racial differences in in vitro fertilization outcomes

BACKGROUND

There are significant racial disparities in in vitro fertilization outcomes, which are poorly explained by individual-level characteristics. Environmental factors such as neighborhood-level socioeconomic factors may contribute to these disparities. However, few studies have directly addressed this research question in a large, racially diverse cohort.

OBJECTIVE

This study aimed to investigate whether neighborhood deprivation is associated with differences in in vitro fertilization outcomes.

STUDY DESIGN

Our retrospective cohort study included 1110 patients who underwent 2254 autologous in vitro fertilization cycles between 2014 and 2019 at an academic fertility center in the Southeastern United States. Neighborhood deprivation was estimated using the Neighborhood Deprivation Index, a composite variable measuring community levels of material capital based on poverty, occupation, housing, and education domains. Using multivariable log-binomial generalized estimating equations with cluster weighting, risk ratios and 95% confidence intervals were estimated for cycle cancellation, miscarriage (defined as spontaneous pregnancy loss before 20 weeks after a confirmed intrauterine gestation), and live birth according to patient Neighborhood Deprivation Index.

RESULTS

There were positive associations between increasing Neighborhood Deprivation Index (indicating worsening neighborhood deprivation) and body mass index, as well as increasing prevalence of tubal and uterine factor infertility diagnoses. The crude probability of live birth per cycle was lower among Black (24%) than among White patients (32%), and the crude probability of miscarriage per clinical pregnancy was higher among Black (22%) than among White patients (12%). After adjustment, the Neighborhood Deprivation Index was not significantly associated with risk of cycle cancellation or live birth. Results were consistent when analyses were stratified by race.

CONCLUSION

Our research demonstrates racial disparities between Black and White women in the incidence of miscarriage and live birth following in vitro fertilization. Although the level of neighborhood deprivation was closely related to race, it did not have strong associations with in vitro fertilization outcomes in our population as a whole or within strata of race.

Correlation of self-reported racial background to euploidy status and live birth rates in assisted reproductive technology cycles

PURPOSE

To determine whether the embryonic euploidy rate and live birth outcomes following single, euploid embryo transfer (SEET) differ among women of self-reported racial and ethnic backgrounds.

METHODS

This retrospective cohort study included all infertile patients of different self-reported racial backgrounds who underwent In vitro fertilization (IVF) with preimplantation genetic testing for aneuploidy (PGT-A) and an autologous single euploid embryo transfer (SEET) from December 2015 to December 2019 at a single private and academic assisted reproduction technology center. Primary outcome measures included ploidy rates among different racial groups. Secondary outcomes included clinical pregnancy, clinical pregnancy loss, and live birth rates.

RESULTS

Five thousand five hundred sixty-two patients who underwent an IVF cycle with ICSI-PGT-A were included. A total of 24,491 blastocysts were analyzed. White participants had on average more euploid embryos and higher euploidy rates when compared to their counterparts (p ≤ 0.0001). However, after controlling for confounding factors, there was no association between race and the odds of having  a higher euploidy rate (aOR 1.31; 95% CI 0.63-2.17, p = 0.42). A total of 4949 patients underwent SEET. Pregnancy outcomes did not differ among patients of varying self-reported races.

CONCLUSIONS

Euploidy rates and pregnancy outcomes were comparable among patients of different racial backgrounds who underwent a SEET.

The knowledge domain and emerging trends in the infertility field: A 67-year retrospective study

Infertility is a significant problem influencing many couples. Our purpose was to assess the field of infertility in Obstetrics and Gynecology from 1955 to 2022 reviewing 3575 documents found in the Web of Science database. Most articles were in the areas of Reproductive Biology, Fertility, Endometriosis & Hysterectomy, and Chromosome Disorders. We found publication has increased dramatically since 1989. Agarwal, Thomas, and Sharma; United States, England, and Canada; Fertility and Sterility, Human Reproduction, and AJOG were the most-cited authors, countries, and journals, respectively. We discovered five substantive clusters: male infertility factors, female infertility factors, causes and treatment of infertility, the consequence of infertility, and assisted reproductive techniques. Using bibliometric review (Co-citation analysis) six research areas were found: semen analysis and sperm morphology, regional differences in the psychological effects of infertility, unexplained infertility, endometriosis, diagnosis and treatment of infertility, and polycystic ovary syndrome. Despite advances in understanding infertility, further research is needed.

Value of painless transvaginal four-dimensional hysterosalpingo contrast sonography in reducing venous intravasation: a comparative study

OBJECTIVE

To investigate the value of painless transvaginal four-dimensional hysterosalpingo contrast sonography (TV 4-D HyCoSy) in reducing venous intravasation and its influencing factors through a retrospective comparative study on conventional TV 4-D HyCoSy.

MATERIALS AND METHODS

A total of 451 patients were enrolled in this study from Jan. 2019 to Oct. 2021. There were 249 patients in the painless TV 4-D HyCoSy group and 202 patients in the conventional TV 4-D HyCoSy group. The incidence of venous intravasation and its related influencing factors were analyzed and compared between these two groups. The difficulty of image evaluation for the diagnosis was also compared.

RESULTS

There was no significant difference in the baseline characteristics between the painless group and the conventional group (p > 0.05). Compared with the conventional group, the painless group had a lower incidence of venous intravasation (16.9 vs. 24.8%; p = 0.039). Painless TV 4-D HyCoSy was more effective in reducing venous intravasation in patients with primary infertility (p = 0.032) without a history of pelvic surgery (p = 0.008) or ectopic pregnancy (p = 0.018). Logistic regression analysis demonstrated that painless TV 4-D HyCoSy and endometrial thickness > 5 mm were protective factors for venous intravasation. Moreover, the diagnostic procedure was easier in the painless group than in the conventional group (p = 0.002).

CONCLUSIONS

Painless TV 4D-HyCoSy may be an effective mode in reducing the incidence of venous intravasation and improving the diagnosis of patency of fallopian tubes.

State insurance mandates and racial and ethnic inequities in assisted reproductive technology utilization

OBJECTIVE

To examine whether the (1) scope of state-mandated insurance coverage for assisted reproductive technology (ART) and (2) proportion of the population eligible for this coverage are associated with reductions in racial/ethnic inequities in ART utilization.

DESIGN

National cross-sectional, ecologic study.

SUBJECTS

We employed estimates from the US Census Bureau of all women 20-44 years of age living in the US in 2018. Data on the number of women who initiated an ART cycle during that year that were reported to the US Centers for Disease Control and Prevention were obtained from the National ART Surveillance System.

EXPOSURE

State mandates were classified according to the scope of required coverage for fertility services: Comprehensive, Limited, and No Mandate.

MAIN OUTCOME MEASURES

Race and ethnic-specific ART utilization rates, defined as the number of women undergoing ≥1 ART cycles per 10,000 women, were the primary outcomes. As state mandates do not apply to all insurance plans, Comprehensive Mandate utilization rates were recalculated using denominators corrected for the estimated proportions of populations eligible for coverage.

RESULTS

Across all mandate categories, Non-Hispanic (NH) Asian and NH White populations had the highest ART utilization rates, whereas the lowest rates were among Hispanic, NH Black, and NH Other/Multiple Races populations. Compared with the NH Asian reference group, the NH Black population had smaller inequities in the Comprehensive Mandate group than the No Mandate group (rate ratio [RR 0.33 [0.28-0.38] vs. RR 0.23 [0.22-0.24]). Using the Comprehensive Mandate group for each race/ethnicity as the reference, the NH Black and NH Other/Multiple Races populations showed the largest relative differences in utilization between the No Mandate and Comprehensive Mandate groups (RR 0.39 [0.37-0.41] and 0.33 [0.28-0.38], respectively). Within the Comprehensive Mandate group, the disparities in the Hispanic and NH Black populations moved toward the null after correcting for state-mandated insurance eligibility.

CONCLUSIONS

Racial/ethnic inequities in ART utilization were reduced in states with comprehensive infertility coverage mandates. Inequities were further attenuated after correcting for mandate eligibility. Mandates alone, however, were not sufficient to eliminate disparities. These findings can inform future strategies aimed at improving ART access under a social justice framework.

Economics of Fertility Care

Family building is a human right. The high cost and lack of insurance coverage associated with fertility treatments in the United States have made treatment inaccessible for many patients. The universal uptake of "add-on" services has further contributed to high out-of-pocket costs. Expansion in access to infertility care has occurred in several states through implementation of insurance mandates, and more employers are offering fertility benefits to attract and retain employees. An understanding of the economic issues shaping fertility should inform future policies aimed at promoting evidence-based practices and improving access to care in the United States.

Racial and Ethnic Disparities in Access to and Outcomes of Infertility Treatment and Assisted Reproductive Technology in the United States

Infertility disproportionately affects the minority, non-White populace, with Black women having twofold higher odds than White women. Despite higher infertility rates, minority racial and ethnic groups access and utilize fertility care less frequently. Even once care is accessed, racial and ethnic disparities exist in infertility treatment and ART outcomes. Preliminary studies indicate that Asian and American Indian women have lower intrauterine insemination pregnancy rates. Many robust studies indicate significant racial and ethnic disparities in rates of clinical pregnancy, live birth, pregnancy loss, and obstetrical complications following in vitro fertilization, with lower favorable outcomes in Black, Asian, and Hispanic women.

Strong social disparities in access to IVF/ICSI despite free cost of treatment: a French population-based nationwide cohort study

BACKGROUND

Access to IVF/ICSI is facilitated when the financial barrier is removed. In a national context where in vitro fertilisation (IVF)/intracytoplasmic sperm Injection (ICSI) treatment is cost-free, how many women do not access IVF/ICSI and what are the factors associated with non-access?

METHODS

Using French national health insurance databases, the cohort included 20,240 women aged 18-43 years living in France who underwent unsuccessful treatment (no pregnancy) with clomiphene citrate (CC) and/or gonadotropins with treatment started between January and August 2016. The outcome measure was non-access to IVF/ICSI during the 24-month following start of infertility care. Factors associated with non-access to IVF/ICSI were explored using mixed effects logistic regression.

RESULTS

In the cohort, 65.4% of women did not access IVF/ICSI. In multivariable analysis, non-access to IVF/ICSI was higher in younger women (18-25 years: (OR 2.17, 95% CI: 1.85-2.54) and in older women (40-43 years: (OR=3.60, 95% CI: 3.25-3.98)). Non-access was higher among women below the poverty line (OR=3.76, 95% CI: 3.34-4.23) and showed a significant upward trend with increasing deprivation of place of residence. Distance to the nearest fertility centre was not significantly associated with non-access to IVF/ICSI.

CONCLUSIONS

In a national context of cost-free ART treatment, a large proportion of women did not access treatment, with a strong social gradient that raises important issues. We need to understand the underlying social mechanisms to develop an efficient and equitable health policy regarding infertility care.

Global burden of pelvic inflammatory disease and ectopic pregnancy from 1990 to 2019

BACKGROUND

Pelvic inflammatory disease (PID) is a widespread female public problem worldwide. And it could lead to infertility, preterm labor, chronic pelvic pain, and ectopic pregnancy (EP) among reproductive-aged women. This study aimed to assess the global burden and trends as well as the chaning correlation between PID and EP in reproductive-aged women from 1990 to 2019.

METHODS

The data of PID and EP among reproductive-aged women (15 to 49 years old) were extracted from the Global Burden of Disease study 2019. The disease burden was assessed by calculating the case numbers and age-standardized rates (ASR). The changing trends and correlation were evaluated by calculating the estimated annual percentage changes (EAPC) and Pearson's correlation coefficient.

RESULTS

In 2019, the ASR of PID prevalence was 53.19 per 100,000 population with a decreasing trend from 1990 (EAPC: - 0.50), while the ASR of EP incidence was 342.44 per 100,000 population with a decreasing trend from 1990 (EAPC: - 1.15). Globally, PID and EP burdens changed with a strong positive correlation (Cor = 0.89) globally from 1990 to 2019. In 2019, Western Sub-Saharan Africa, Australasia, and Central Sub-Saharan Africa had the highest ASR of PID prevalence, and Oceania, Eastern Europe, and Southern Latin America had the highest ASR of EP incidence. Only Western Europe saw significant increasing PID trends, while Eastern Europe and Western Europe saw increasing EP trends. The highest correlations between PID and EP burden were observed in Burkina Faso, Laos, and Bhutan. General negative correlations between the socio-demographic index and the ASR of PID prevalence and the ASR of EP incidence were observed at the national levels.

CONCLUSION

PID and EP continue to be public health burdens with a strong correlation despite slightly decreasing trends detected in ASRs globally. Effective interventions and strategies should be established according to the local situation by policymakers.

Navigating Unequal Paths: Racial Disparities in the Infertility Journey

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.

Socioeconomic disparities in fertility treatments and associated likelihood of livebirth following in vitro fertilization

OBJECTIVE

To determine whether neighborhood-level socioeconomic characteristics are associated with the likelihood of livebirth (LB) following in vitro fertilization (IVF). Specifically, we evaluated neighborhood-level household income, unemployment rate, and educational attainment.

DESIGN

A retrospective cross-sectional study was conducted for patients undergoing autologous IVF cycles.

SETTING

Large academic health system.

INTERVENTIONS

For each patient, ZIP code of residence was used as a proxy for neighborhood. Neighborhood characteristics were compared between patients with and without LB. Generalized estimating model was used to adjust the association between SES factors and likelihood of a live birth with respect to relevant clinical factors.

RESULTS

A total of 4942 autologous IVF cycles from 2768 patients were included: 1717 (62.0%) had at least one associated LB. Patients who achieved LB from IVF were younger, had higher anti-Mullerian hormone (AMH) levels, lower body mass index (BMI), and differed by ethnic background, primary language, and neighborhood socioeconomic characteristics. In a multivariable model, language, age, AMH, and BMI were associated with a live birth from IVF. None of the neighborhood-level socioeconomic variables were associated with the total number of IVF cycles or cycles required to achieve first LB.

CONCLUSION

Patients living in neighborhoods with lower annual household income have lower odds of livebirth after IVF compared to those living in more affluent areas, despite undergoing the same number of IVF stimulation cycles.

Fertility Preservation Decisional Turning Points for Adolescents and Young Adults With Cancer: Exploring Alignment and Divergence by Race and Ethnicity

PURPOSE

For adolescents and young adults (AYAs) with cancer, fertility preservation (FP) decision making is complex and distressing. Racial/ethnic minority (REM) AYAs experience disparities in FP awareness, uptake, and outcomes. A turning point (TP) is a point of reflection, change, or decisive moment(s) resulting in changes in perspectives or trajectories. To enhance understanding of AYAs' diverse experiences, this study examined alignment and/or divergence of FP decisional TPs among non-Hispanic White (NHW) AYAs and REM AYAs.

METHODS

Qualitative semistructured interviews were conducted in person, by video, or phone with 36 AYAs (20 NHW and 16 REM [nine Hispanic and seven Black/multiracial Black). The constant comparative method was used to identify and analyze themes illustrating participants' conceptualization and/or experience of FP decisional TPs.

RESULTS

Seven thematic TPs emerged: (1) emotional reaction to discovering FP procedures exist; (2) encountering unclear or dismissive communication during initial fertility conversations with health care providers; (3) encountering direct and supportive communication during initial fertility conversations with health care providers; (4) participating in critical family conversations about pursuing FP; (5) weighing personal desire for a child against other priorities/circumstances; (6) realizing FP is not feasible, and (7) experiencing unanticipated changes in cancer diagnosis or treatment plans/procedures. TP variations include REM participants reported dismissive communication and suggested cost was prohibitive. NHW participants emphasized more forcefully that biological children may become a future priority.

CONCLUSION

Understanding how clinical communication and priorities/resources may vary for NHW and REM AYAs can inform future interventions aimed at reducing health disparities and enhancing patient-centered care.

Exploratory study of race- or ethnicity-based discrimination among patients receiving procedural abortion care

OBJECTIVE

Explore relationships of race and ethnicity with experiences of race- or ethnicity-based discrimination during abortion care.

STUDY DESIGN

English- or Spanish-speaking individuals aged 18 to 50 completed cross-sectional, self-administered online surveys within 30 days of procedural abortion at 5 Northeastern U.S. reproductive health clinics from June 2020 toFebruary 2021. We considered any affirmative response on the Discrimination in Medical Settings (DMS) scale evidence of race- or ethnicity-based discrimination. We performed bivariate analyses and logistic regression examining discrimination among Black non-Latinx, Latinx any race, Other race non-Latinx compared to White non-Latinx participants. We assessed associations between discrimination and healthcare quality and satisfaction.

RESULTS

Participants (n = 163) averaged 27(±6) years and self-identified as Black non-Latinx (36.2%), White non-Latinx (28.8%), Latinx of any race (27.0%), and Other non-Latinx (8.0%). Most were publicly insured (52.8%) and <14 weeks gestation (90.8%).Overall, 15.3% reported race- or ethnicity-based discrimination during abortion care with Black non-Latinx more likely to report discrimination (23.7%; OR 7.00, 95% CI 1.50-32.59), while Latinx any race (15.9%, OR 4.26, 95% CI 0.83-21.74) and Other race non-Latinx participants (15.4%, OR 4.09, 95% CI 0.52-32.35) demonstrated statistically nonsignificant trend toward increased odds of discrimination compared to White non-Latinx (4.3%). Discrimination was associated with negative perceptions of: time with physician (p = 0.03), patient care involvement (p < 0.05), physician communication (p = 0.01), care quality (p = 0.02), and care satisfaction (p < 0.01).

CONCLUSION

Racially minoritized participants were more likely to report race- or ethnicity-based discrimination during abortion care; Black non-Latinx reported highest odds of discrimination compared to White non-Latinx. Discrimination was associated with unfavorable healthcare quality measures.

IMPLICATIONS

Race- or ethnicity-based discrimination during abortion care is disproportionately reported by racially minoritized populations, especially Black individuals, compared to White non-Latinx individuals. Discrimination is significantly associated with negative experiences of care. Future work should verify findings in different regions and larger studies, and design and test discrimination-reduction interventions.

Reproductive Health Counseling among Youth with Sickle Cell Disease

STUDY OBJECTIVE

Reproductive health counseling is important for youth with sickle cell disease (SCD) given they experience potential infertility risks from SCD and its treatments and high rates of unplanned pregnancies. Thus, the objective was to describe documented occurrences of reproductive health counseling among youth with SCD and examine differences in counseling by sociodemographic and treatment characteristics.

METHODS

Data were abstracted from 167 electronic medical records (age=14-21, 54% female) with SCD (1/01/2015-12/31/19) at two sites (Nationwide Children's Hospital [NCH] and Hassenfeld Children's Hospital at NYU Langone [HCH]). Descriptive statistics, Point-biserial correlations and Chi Square tests were used to examine sample characteristics and relationships between sociodemographic factors, clinical characteristics, site, and reproductive health counseling (fertility, contraception, and genetic counseling).

RESULTS

Seven of 167 (4%) youth had documented discussions about potential impacts of SCD on fertility. Fertility counseling was also low among those who received a bone marrow transplant (BMT) or hydroxyurea (n=1/2; 50% and n=1/104; 1% respectively). Only 57% of youth received contraception counseling and only 55% of sexually active youth used birth control; birth control use was associated with older age (p=0.028), severe clinical disease (p=0.003), and documentation of contraception counseling (p=0.047). Most youth received genetic counseling (80%), though more genetic counseling occurred at NCH (p<0.001). There was no association between gender and any type of counseling.

CONCLUSION

Findings suggest reproductive health counseling gaps in this population with important implications for future infertility distress and unplanned pregnancies. Future research should examine barriers to counseling, explore fertility impacts of SCD and treatments, and inform evidence-based guidelines for reproductive health care in SCD.

Direct-to-consumer fertility testing: utilization and perceived utility among fertility patients and reproductive endocrinologists

RESEARCH QUESTION

What is the utilization of direct-to-consumer fertility tests (DTCFT) among fertility patients? How does the perceived utility of DTCFT differ between patients and reproductive endocrinologists (REI)?

DESIGN

Infertility patients visiting the Duke Fertility Center between December 2020 and December 2021 were sent an electronic invitation to participate in a patient survey. Members of the Society of Reproductive Endocrinology and Infertility were also sent e-mail invitations to participate in the REI survey. DTCFT were defined as tests not ordered by a physician or performed at a physician's office, including calendar methods of ovulation prediction, urinary ovulation prediction kits, basal body temperature (BBT) monitoring, hormone analysis, ovarian reserve testing and semen analysis. Patients and REI were asked how likely they were to recommend a given DTCFT, on a 0-10 Likert scale.

RESULTS

In total, 425 patients (response rate 50.5%) and 178 REI (response rate 21.4%) completed the surveys. Patients reported the utilization of calendar methods of ovulation prediction (83.8%), urinary ovulation prediction (78.8%), BBT monitoring (30.8%), hormone analysis (15.3%), semen analysis (10.1%) and ovarian reserve testing (9.2%). REI rated the utility of all DTCFT significantly lower than patients did (average discordance -4.2, P < 0.001), except for urinary ovulation prediction, which REI gave a significantly higher score (discordance +1.0, P < 0.001). Prior pregnancy was significantly associated with home ovulation prediction utilization among patients (adjusted odds ratio 3.21, 95% confidence interval 1.2-9.83).

CONCLUSIONS

Methods of ovulation prediction are commonly used by fertility patients. Significant discordance exists in the perceived utility of DTCFT between patients and REI. Patient education and guidelines are needed to better inform individuals considering DTCFT.

Association of state insurance coverage mandates with assisted reproductive technology care discontinuation

BACKGROUND

Insurance coverage for fertility services may reduce the financial burden of high-cost fertility care such as assisted reproductive technology and improve its utilization. Patients who exit care after failing to reach their reproductive goals report higher rates of mental health problems and a lower sense of well-being. It is important to understand the relationship between state-mandated insurance coverage for fertility services and assisted reproductive technology care discontinuation.

OBJECTIVE

This study aimed to assess whether state-mandated insurance coverage for fertility services is associated with lower rates of care discontinuation after an initial assisted reproductive technology cycle that did not result in a live birth.

STUDY DESIGN

This is a retrospective, population-based cohort study using data from United States fertility clinics reporting to the National Assisted Reproductive Technology Surveillance System during 2016 and 2018. Patients who began their first autologous assisted reproductive technology cycle during 2016 and 2017 and did not have a live birth were included. We describe the rate of assisted reproductive technology care discontinuation (no additional cycle within 12 months of the previous cycle's date of failure). Multivariable analyses were conducted to evaluate factors independently associated with care discontinuation, including the scope of fertility services included in state coverage mandate at assisted reproductive technology cycle initiation that were as follows: comprehensive (≥3 assisted reproductive technology cycles), limited (1, 2, or an unspecified number of assisted reproductive technology cycles), mandate not including assisted reproductive technology, and no mandate.

RESULTS

Among 91,324 patients who underwent their first autologous assisted reproductive technology cycle that did not result in live birth, 24,072 (26.4%) discontinued care. Compared with patients who lived in states with mandates for comprehensive assisted reproductive technology coverage, those in states with mandates for fertility services coverage that did not include assisted reproductive technology or states with no mandate were 46% (adjusted relative risk, 1.46; 95% confidence interval, 1.31-1.63) and 26% (adjusted relative risk, 1.26; 95% confidence interval, 1.15-1.39) more likely to discontinue care, respectively, after controlling for patient and cycle characteristics. Increasing patient age, distance from clinic ≥50 miles, previous live birth, fewer oocytes retrieved, and not having embryos cryopreserved were also associated with higher rates of discontinuation. Non-Hispanic Black, non-Hispanic Asian, and Hispanic patients had higher rates of care discontinuation than non-Hispanic White patients regardless of the existence or scope of state-mandated assisted reproductive technology coverage.

CONCLUSION

Comprehensive state-mandated insurance coverage for assisted reproductive technology is associated with lower rates of assisted reproductive technology care discontinuation.

Accessing medical care for infertility: a study of women in Mexico

Objective

To investigate barriers in accessing care for infertility in Mexico, because little is known about this issue for low and middle-income countries, which comprise 80% of the world's population.

Design

Cross-sectional analysis.

Setting

Mexcian Teachers' Cohort.

Patients

A total of 115,315 female public school teachers from 12 states in Mexico.

Interventions

None.

Main Outcome Measures

The participants were asked detailed questions about their demographics, lifestyle characteristics, access to the health care system, and infertility history via a self-reported questionnaire. Log-binomial models, adjusted a priori for potential confounding factors, were used to estimate the prevalence ratios (PRs) and 95% confidence intervals ( CIs) of accessing medical care for infertility among women reporting a history of infertility.

Results

A total of 19,580 (17%) participants reported a history of infertility. Of those who experienced infertility, 12,470 (63.7%) reported seeking medical care for infertility, among whom 8,467 (67.9%) reported undergoing fertility treatments. Among women who reported a history of infertility, women who taught in a rural school (PR, 0.95; 95% CI, 0.92-0.97), spoke an indigenous language (PR, 0.88; 95% CI, 0.84-0.92), or had less than a university degree (PR, 0.93; 95% CI, 0.90-0.97) were less likely to access medical care for fertility. Women who had ever had a mammogram (PR, 1.07; 95% CI, 1.05-1.10), had a pap smear in the past year (PR, 1.08; 95% CI, 1.06-1.10), or who had used private health care regularly or in times of illness were more likely to access medical care for fertility.

Conclusions

The usage of infertility care varied by demographic, lifestyle, and access characteristics, including speaking an indigenous language, teaching in a rural school, and having a private health care provider.

Urinary phenol concentrations and fecundability and early pregnancy loss

STUDY QUESTION

Are urinary phenol concentrations of methylparaben, propylparaben, butylparaben, triclosan, benzophenone-3, 2,4-dichlorophenol or 2,5-dichlorophenol associated with fecundability and early pregnancy loss?

SUMMARY ANSWER

2,5-dichlorophenol concentrations were associated with an increased odds of early pregnancy loss, and higher concentrations of butylparaben and triclosan were associated with an increase in fecundability.

WHAT IS KNOWN ALREADY

Phenols are chemicals with endocrine-disrupting potential found in everyday products. Despite plausible mechanisms of phenol reproductive toxicity, there are inconsistent results across few epidemiologic studies examining phenol exposure and reproductive function in non-fertility treatment populations.

STUDY DESIGN, SIZE, DURATION

Specimens and data were from the North Carolina Early Pregnancy Study prospective cohort of 221 women attempting to conceive naturally from 1982 to 1986. This analysis includes data from 221 participants across 706 menstrual cycles, with 135 live births, 15 clinical miscarriages and 48 early pregnancy losses (before 42 days after the last menstrual period).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants collected daily first-morning urine specimens. For each menstrual cycle, aliquots from three daily specimens across the cycle were pooled within individuals and analyzed for phenol concentrations. To assess sample repeatability, we calculated intraclass correlation coefficients (ICCs) for each phenol. We evaluated associations between phenol concentrations from pooled samples and time to pregnancy using discrete-time logistic regression and generalized estimating equations (GEE), and early pregnancy loss using multivariable logistic regression and GEE.

MAIN RESULTS AND THE ROLE OF CHANCE

ICCs for within-person variability across menstrual cycles in pooled phenol concentrations ranged from 0.42 to 0.75. There was an increased odds of early pregnancy loss with 2,5-dichlorophenol concentrations although the CIs were wide (5th vs 1st quintile odds ratio (OR): 4.79; 95% CI: 1.06, 21.59). There was an increased per-cycle odds of conception at higher concentrations of butylparaben (OR: 1.62; 95% CI: 1.08, 2.44) and triclosan (OR: 1.49; 95% CI: 0.99, 2.26) compared to non-detectable concentrations. No associations were observed between these endpoints and concentrations of other phenols examined.

LIMITATIONS, REASONS FOR CAUTION

Limitations include the absence of phenol measurements for male partners and a limited sample size, especially for the outcome of early pregnancy loss, which reduced our power to detect associations.

WIDER IMPLICATIONS OF THE FINDINGS

This study is the first to use repeated pooled measures to summarize phenol exposure and the first to investigate associations with fecundability and early pregnancy loss. Within-person phenol concentration variability underscores the importance of collecting repeated samples for future studies. Exposure misclassification could contribute to differences between the findings of this study and those of other studies, all of which used one urine sample to assess phenol exposure. This study also contributes to the limited literature probing potential associations between environmental exposures and early pregnancy loss, which is a challenging outcome to study as it typically occurs before a pregnancy is clinically recognized.

STUDY FUNDING/COMPETING INTEREST(S)

This research was supported by the National Institute of Environmental Health Sciences of the National Institutes of Health (award number F31ES030594), the Intramural Research Program of the National Institutes of Health, the National Institute of Environmental Health Sciences (project numbers ES103333 and ES103086) and a doctoral fellowship at the Yale School of Public Health. The authors declare they have no competing interests to disclose.

TRIAL REGISTRATION NUMBER

N/A.

Association of State Insurance Mandates for Fertility Treatment With Multiple Embryo Transfer After Preimplantation Genetic Testing for Aneuploidy

IMPORTANCE

Multiple gestation is one of the biggest risks after in vitro fertilization (IVF), largely due to multiple embryo transfer (MET). Single embryo transfer (SET) uptake has increased over time and has been attributed to various factors, such as mandated insurance coverage for IVF and preimplantation genetic testing for aneuploidy (PGT-A).

OBJECTIVE

To investigate whether mandates for IVF insurance coverage are associated with decreased use of MET after PGT-A.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted using data on embryo transfers reported to the Society for Assisted Reproductive Technology between 2014 and 2016. Data were analyzed from January to October 2021.

EXPOSURES

State-mandated coverage for fertility treatment and type of cycle transfer performed (PGT-A, untested fresh, and untested frozen).

MAIN OUTCOMES AND MEASURES

Use of MET compared with SET, live birth, and live birth of multiples.

RESULTS

There were 110 843 embryo transfers (mean [SD] patient age, 34.0 [4.5] years; 5520 individuals identified as African American [5.0%], 10 035 as Asian [9.0%], 5425 as Hispanic [4.9%], 45 561 as White [41.1%], and 44 302 as other or unknown race or ethnicity [40.0%]); 17 650 transfers used embryos that underwent PGT-A. Overall, among transferred embryos that had PGT-A, there were 9712 live births (55.0%). The odds of live birth were 70% higher with MET vs SET after frozen embryo transfer with PGT-A (OR, 1.70; 95% CI, 1.61-1.78), but the risk of multiples was 5 times higher (OR, 5.33; 95% CI, 5.22-5.44). The odds of MET in cycles with PGT-A in states with insurance mandates were 24% lower than in states without mandates (OR, 0.76; 95% CI, 0.68-0.85).

CONCLUSIONS AND RELEVANCE

This study found that despite the promise of using SET with PGT-A, MET after PGT-A was not uncommon. This practice was more common in states without insurance mandates and was associated with a high risk of multiples.

The association between pregnancy intention, fertility treatment use, and postpartum depression

RATIONALE

Understanding whether postpartum depressive (PPD) symptoms vary by pregnancy intention and use of fertility treatments has implications for reproductive health policies and practices.

OBJECTIVE

The first aim of this study was to determine whether PPD symptoms differ between women who had unintended pregnancies, women who conceived spontaneously and were unsure about their pregnancy intention, women who used fertility treatments to conceive, and women who conceived spontaneously and intentionally. The second aim was to determine whether PPD symptoms differed based on the fertility treatment used to conceive (fertility drugs only, medicated insemination, or assisted reproductive technology [ART]).

METHODS

Data from the Pregnancy Risk Assessment Monitoring System (2012-2019), a cross-sectional survey administered to women throughout the U.S. who have recently given birth, was used to carry out our aims.

RESULTS

For the first aim (unweighted N = 243,677), compared to women who had spontaneous, intended pregnancies, women who had unintended pregnancies (OR: 1.32, 95% CI: 1.26-1.39, p < 0.01) and those with spontaneous pregnancies who were unsure about their intention (OR: 1.30, 95% CI: 1.23-1.38, p < 0.01) had higher odds of elevated PPD symptoms, adjusting for a range of covariates. Women who conceived with fertility treatments did not have higher odds of elevated PPD symptoms (OR: 0.97, 95% CI: 0.84-1.10, p = 0.61). For the second aim (unweighted N = 2,210), compared to those in the ART group, those who conceived using only fertility enhancing drugs had greater odds of developing elevated PPD symptoms (OR: 2.00, 95% CI: 1.24-3.24, p < 0.01).

CONCLUSIONS

These findings suggest that giving birth to an unintended pregnancy in the U.S. increases risk of elevated PPD symptoms. While overall women who conceive with the use of fertility treatments are not at increased risk of experiencing elevated PPD symptoms, there may be variability in risk based on the specific fertility treatments used.

Racial and Ethnic Disparities in the Perinatal Health of Infants Conceived by ART

BACKGROUND AND OBJECTIVES

Although racial and ethnic disparities in adverse birth outcomes have been well documented, it is unknown whether such disparities diminish in women who use medically assisted reproduction (MAR). We examined differences in the association between maternal race and ethnicity and adverse birth outcomes among women who conceived spontaneously and those who used MAR, including assisted reproduction technology (ART), eg, in-vitro fertilization, and also non-ART MAR, eg, fertility drugs.

METHODS

We conducted a population-based retrospective cohort study using data on all singleton births (N = 7 545 805) in the United States from 2016 to 2017. The outcomes included neonatal and fetal death, preterm birth, and serious neonatal morbidity, among others. Modified Poisson regression was used to estimate adjusted rate ratios (aRR) and 95% confidence intervals (CI) and to assess the interactions between race and ethnicity and mode of conception.

RESULTS

Overall, 93 469 (1.3%) singletons were conceived by MAR. Neonatal mortality was twofold higher among infants of non-Hispanic Black versus non-Hispanic White women in the spontaneous-conception group (aRR = 1.9, 95% CI: 1.8-1.9), whereas in the ART-conception group, neonatal mortality was more than fourfold higher in infants of non-Hispanic Black women (aRR = 4.1, 95% CI: 2.9-5.9). Racial and ethnic disparities between Hispanic versus non-Hispanic White women were also significantly larger among women who conceived using MAR with regard to preterm birth (&lt;34 weeks) and perinatal mortality.

CONCLUSIONS

Compared to women who conceived spontaneously, racial and ethnic disparities in adverse perinatal outcomes were larger in women who used MAR. More research is needed to identify preventive measures for reducing risks among vulnerable women who use medically assisted reproduction.

Mode of conception and risk of spontaneous vs. provider-initiated preterm birth: population-based cohort study

OBJECTIVE

To study the association between mode of conception and risk of preterm birth, including, spontaneous and provider-initiated subtypes.

DESIGN

Population-based retrospective cohort study.

SETTING

Not applicable.

PATIENTS

All singleton livebirths and stillbirth in Ontario, Canada, 2006-2014.

INTERVENTION

The main exposure was mode of conception, namely unassisted conception, infertility without fertility treatment (i.e., known infertility but conceived without assistance), ovulation induction (OI) or intrauterine insemination (IUI), and in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). Modified Poisson regression generated risk ratios (RRs) and 95% confidence intervals for the association between exposure categories and preterm birth adjusted for clinically relevant covariates using a propensity score.

MAIN OUTCOME MEASURE(S)

The primary outcome was preterm birth <37 weeks, further categorized as spontaneous or provider-initiated subtypes. The secondary outcome was preterm birth <34 weeks.

RESULTS

We included 732,810 singleton births born to 649,918 mothers, of which 646,926 (88.3%) were from an unassisted conception, 68,822 (9.4%) with infertility but no fertility treatment, 9,024 (1.2%) following OI/IUI, and 8,038 (1.1%) following IVF/ICSI. Preterm birth <37 weeks occurred among 6.0% of births by unassisted conception, 7.7% with infertility without fertility treatment, 8.0% with OI/IUI, and 10.8% following IVF/ICSI. Relative to unassisted conception, the unadjusted RR of provider-initiated preterm birth was 1.30 (1.26-1.33) in women with infertility without fertility treatment, 1.36 (1.26-1.45) after OI/IUI, and 1.82 (1.70-1.93) after IVF/ICSI. The corresponding adjusted RRs (aRR) were 1.23 (1.16-1.31), 1.48 (1.29-1.69), and 2.35 (2.09-2.64). The unadjusted RR of spontaneous preterm birth was 1.22 (1.18-1.27) in women with infertility without fertility treatment, 1.22 (1.12-1.34) after OI/IUI, and 1.47 (1.35-1.60) after IVF/ICSI. The corresponding aRR were 1.15 (1.10-1.19), 1.19 (1.09-1.31), and 1.40 (1.27-1.53). For preterm birth <34 weeks, the RRs followed a similar pattern as for preterm birth <37 weeks, with the exception of women with infertility without fertility treatment (aRR 1.08; confidence interval, 0.95-1.23).

CONCLUSIONS

Infertility and receipt of fertility treatment are each associated with a higher risk of preterm birth, spontaneous and provider-initiated subtypes, even in singleton pregnancies. Strategies are needed to reduce the risk for preterm birth in these women.

Impact of in vitro fertilization state mandates for third party insurance coverage in the United States: a review and critical assessment

The American Society for Reproductive Medicine estimates that fewer than a quarter of infertile couples have sufficient access to infertility care. Insurers in the United States (US) have long considered infertility to be a socially constructed condition, and thus in-vitro fertilization (IVF) an elective intervention. As a result, IVF is cost prohibitive for many patients in the US. State infertility insurance mandates are a crucial mechanism for expanding access to fertility care in the US in the absence of federal legislation. The first state insurance mandate for third party coverage of infertility services was passed by West Virginia in 1977, and Maryland passed the country's first IVF mandate in 1985. To date, twenty states have passed legislation requiring insurers to cover or offer coverage for the diagnosis and treatment of infertility. Ten states currently have "comprehensive" IVF mandates, meaning they require third party coverage for IVF with minimal restrictions to patient eligibility, exemptions, and lifetime limits. Several studies analyzing the impact of infertility and IVF mandates have been published in the past 20 years. In this review, we characterize and contextualize the existing evidence of the impact of state insurance mandates on access to infertility treatment, IVF practice patterns, and reproductive outcomes. Furthermore, we summarize the arguments in favor of insurance coverage for infertility care and assess the limitations of state insurance mandates as a strategy for increasing access to infertility treatment. State mandates play a key role in the promotion of evidence-based practices and represent an essential and impactful strategy for the advancement of gender equality and reproductive rights.

Racial disparities in access to reproductive health and fertility care in the United States

PURPOSE OF REVIEW

To examine the status of racial and ethnic inequalities in fertility care in the United States (U.S.) at inception of 2022. This review highlights addressable underpinnings for the prevalent differentials in access to and utilization of infertility treatments and underscores gaps in preventive care as key contributors to racial and ethnic disparities in risk burden for subfertility and infertility.

RECENT FINDINGS

Significant gaps in access to and utilization of fertility care are consistently reported among racial and ethnic minorities, particularly Black and Hispanic women. Access to and utilization of contraceptives, human papilloma virus vaccination rates, preexposure prophylaxis use, and differentials in treatment of common gynecologic disorders are relevant to the prevalent racial and ethnic disparities in reproductive health. The spectrum of differential in reproductive wellness and the magnitude of reproductive health burden afflicting racial minorities in the U.S. raise concerns regarding systemic and structural racism as plausible contributors to the prevalent state of affairs.

SUMMARY

Despite efforts to reform unequal reproductive health practices and policies, racial and ethnic disparities in fertility care are pervasive and persistent. In addition to measures aimed at reducing barriers to care, societal efforts must prioritize health disparity research to systematically examine underpinnings, and addressing structural racism and interpersonal biases, to correct the prevalent racial inequities and mitigate disparities.

Impact of race versus ethnicity on infertility diagnosis between Black American, Haitian, African, and White American women seeking infertility care: a retrospective review

Objective

To determine whether infertility diagnoses differ between Black ethnic subgroups.

Design

Retrospective review.

Setting

an urban safety-net hospital.

Patient(s)

Women seeking infertility care between 2005 and 2015.

Intervention(s)

Charts of women with infertility and polycystic ovary syndrome (International Classification of Diseases, Ninth Revision diagnoses) were reviewed to confirm diagnoses. Data were stratified by race and subsequently by ethnicity to evaluate the differences in infertility diagnoses between Black American, Black Haitian, and Black African women. White American women were used as the comparison group.

Main Outcome Measure(s)

Infertility diagnoses between Black ethnic subgroups and White women.

Result(s)

A total of 358 women met the inclusion criteria, including 99 Black American, 110 Black Haitian, 61 Black African, and 88 White American women. Anovulation/polycystic ovary syndrome was the most common diagnosis in each ethnic group, accounting for 40% of infertility among White American, 57% among Black American, 25% among Black Haitian, and 21% among Black African women. There were no significant differences in the individual infertility diagnoses between Black and White women. Between ethnic subgroups, multivariate analysis showed significantly higher odds of infertility because of anovulation/polycystic ovary syndrome in Black American women compared with Black African women (odds ratio [OR], 4.9; 95% confidence interval [CI], 1.4–17.0). Compared with Black African women, higher odds of tubal factor infertility were observed in Black American (OR, 4.7; 95% CI, 1.16–18.7) and Black Haitian women (OR, 4.0; 95% CI, 1.1–14.0).

Conclusion(s)

Infertility diagnoses were not homogeneous across Black ethnic groups. Studies examining infertility should specify the ethnic subgroups within a race because this may affect results.

See one, do one, teach one: Reimagining reproductive endocrinology and infertility training programs to expand access to care

Objective

To provide a review of the current literature surrounding barriers to reproductive medicine and present examples of how resident and fellow education can be used to overcome these barriers.

Design

A review of the relevant literature addressing barriers to reproductive medicine, resident and fellow education, and related materials was completed.

Setting

Academic medical institutions.

Patient(s)

None.

Intervention(s)

None.

Main Outcome Measure(s)

Health disparities and barriers in access to care.

Result(s)

Of barriers in access to care, 3 were reviewed in detail: cost of health care, racial inequities, and marginalization of immigrant communities. The suggested strategies to mitigate these barriers include the following: reducing racial inequities through improved diversity within reproductive medicine and through antiracism training, developing opportunities for trainees to engage in advocacy, strengthening reproductive endocrinology and infertility clinical exposure and educational curricula in training programs, inclusion of residents and fellows in clinical care, and improving the accessibility of fertility care through implementing approaches to optimize the management of infertility in challenging, resource-constrained settings.

Conclusion(s)

Infertility is one of the most prevalent reproductive health diseases, yet profound disparities and inequities in access to care exist today in the United States. Lower-income, minority, and immigrant communities are among those most marginalized. Improved access to care begins with broadened obstetrics and gynecology and reproductive endocrinology and infertility trainee education, which acknowledges the barriers these communities face and provides strategies to help overcome these obstacles to care.

Women's preventive services initiative: fertility counseling overlooked

The 2021 Women's Preventive Services Initiative Well-Woman Chart outlines a framework for incorporating preventive health services recommended by the Women's Preventive Services Initiative, the US Preventive Services Task Force, and Bright Futures based on age, health status, and risk factors. Following the previous guidelines for preventive care, this document failed to offer recommendations or guidelines for infertility screening and fertility counseling in the course of well-woman care. Healthcare providers may be less likely to address fertility with their patients in the absence of clear, evidence-based recommendations, potentially resulting in underinformed reproductive choices and compromised reproductive potential. Given the devastating consequences of infertility and unintended childlessness, we, herein, propose that infertility screening and fertility counseling should become an integral part of well-woman care and that organizations, such as the Women's Preventive Services Initiative, put forth guidelines to assist providers in addressing fertility throughout a woman's reproductive lifespan.

State-Mandated Insurance Coverage and Preimplantation Genetic Testing in the United States

OBJECTIVE

To examine the association between state-mandated insurance coverage for infertility treatment in the United States and the utilization of and indication for preimplantation genetic testing.

METHODS

This was a retrospective cohort study of 301,465 in vitro fertilization (IVF) cycles reported to the Society for Assisted Reproductive Technology between 2014 and 2016. Binomial logistic regression was performed to examine associations between state-mandated insurance coverage and preimplantation genetic testing use. The neonate's sex from each patient's first successful cycle was used to calculate sex ratios. Sex ratios then were compared by state mandates and preimplantation genetic testing indication for elective sex selection.

RESULTS

The proportion of IVF cycles using preimplantation genetic testing increased from 17% in 2014 to 34% in 2016. This increase was driven largely by preimplantation genetic testing for aneuploidy testing. Preimplantation genetic testing was less likely to be performed in states with mandates for insurance coverage than in those without mandates (risk ratio [RR] 0.69, 95% CI 0.67-0.71, P<.001). Preimplantation genetic testing use for elective sex selection was also less likely to be performed in states with mandates (RR 0.44, 95% CI 0.36-0.53, P<.001). Among liveborn neonates, the male/female sex ratio was higher for IVF cycles with preimplantation genetic testing for any indication (115) than for those without preimplantation genetic testing (105) (P<.001), and the use of preimplantation genetic testing specifically for elective sex selection had a substantially higher (164) male/female sex ratio than preimplantation genetic testing for other indications (112) (P<.001).

CONCLUSION

The proportion of IVF cycles using preimplantation genetic testing in the United States is increasing and is highest in states where IVF is largely self-funded. Preimplantation genetic testing for nonmedical sex selection is also more common in states where IVF is self-funded and is more likely to result in male offspring. Continued surveillance of these trends is important, because these practices are controversial and could have implications for future population demographics.

The Disparities in ART (DART) Hypothesis of Racial and Ethnic Disparities in Access and Outcomes of IVF Treatment in the USA

We propose the Disparities in ART (DART) hypothesis which identifies underlining causes that contribute to racial disparities in access and outcomes of ART treatment in the USA. Reasons for disparities in access and outcomes of ART treatment for infertility are derived from some relative contribution of four identified causes. They are simply stated as delays in obtaining treatment, higher dropout during and following unsuccessful ART treatment, provider factors, and differences in patient biological factors. Each of these causes has a subset of 4-6 factors that contribute to each of the 4 broad categorical causes that are discussed. This hypothesis may serve as a platform for better understanding the scope of the challenges and potential research inquiries that may lead to narrowing of racial/ethnic disparities in access and outcomes in ART.

Racial/ethnic disparities in infertility treatment utilization in the US, 2011-2019

With delayed child-bearing age, there has been an increase in infertility rates globally and in the United States (US). Unsurprisingly, there has been a concomitant substantial increase in the number of individuals seeking infertility treatments over the last decade. This study aimed to examine the relationship between race/ethnicity and the utilization of different infertility treatments over the previous decade. We conducted this retrospective cohort study using the United States (US) Birth data files 2011-2019. We calculated the rates of infertility treatment and its subtypes over the study period. Descriptive statistics were utilized to examine the sociodemographic and birth characteristics for overall births and those associated with any infertility treatment and each of its subtypes. We calculated the level of association between race/ethnicity and utilization of infertility treatment and the subtypes using adjusted logistic regression models. We found that the rate of infertility treatments for all subtypes considered, had steadily increased by 63.7% within the past decade. In contrast, fertility enhancing drugs or Intrauterine Insemination (IUI) increased by 134%, and in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), and zygote intrafallopian transfer (ZIFT) treatments increased by 40% over the 9-year study period. Non-Hispanic (NH) Asian women had the highest rate of any infertility treatment with a rate of 25 per 1000 births whereas Hispanic women had the lowest rate of any infertility treatment at 5.8 per 1000 births. When compared with NH-White women, NH-Asian women had a modest 7% lower likelihood (OR = 0.93, 95% CI = 0.92-0.94) of receiving any infertility treatment while NH-Black and Hispanic women had about 70% lower likelihood of receiving any infertility treatment. Our report of increased assisted reproductive technology (ART) utilization rates, and marked racial/ethnic differences in ART utilization highlight the importance of expanding knowledge of inequities that continue to impact marginalized groups, a critical step for informing actionable strategy formulations (i.e., advocacy, policy change, patient education, provider training) to address these inequities.

Tubal factor infertility and its impact on reproductive freedom of African American women

In the past, the reproductive freedom of African American women was hindered by forced reproduction and sterilization campaigns. Unfortunately, these involuntary practices have now mostly been replaced by inequality because of disproportionate tubal factor infertility rates within African American communities. Our work aimed to describe the inequities in increased rates of pelvic inflammatory disease and tubal factor infertility as it relates to African American women. In addition, we highlighted the need for improved access to screening and treatment of sexually transmitted infections, access to barrier contraception, and health literacy related to the understanding and prevention of tubal factor infertility in African American women.

Population-wide contribution of medically assisted reproductive technologies to overall births in Australia: temporal trends and parental characteristics

STUDY QUESTION

In a country with supportive funding for medically assisted reproduction (MAR) technologies, what is the proportion of MAR births over-time?

SUMMARY ANSWER

In 2017, 6.7% of births were conceived by MAR (4.8% ART and 1.9% ovulation induction (OI)/IUI) with a 55% increase in ART births and a stable contribution from OI/IUI births over the past decade.

WHAT IS KNOWN ALREADY

There is considerable global variation in utilization rates of ART despite a similar infertility prevalence worldwide. While the overall contribution of ART to national births is known in many countries because of ART registries, very little is known about the contribution of OI/IUI treatment or the socio-demographic characteristics of the parents. Australia provides supportive public funding for all forms of MAR with no restrictions based on male or female age, and thus provides a unique setting to investigate the contribution of MAR to national births as well as the socio-demographic characteristics of parents across the different types of MAR births.

STUDY DESIGN, SIZE, DURATION

This is a novel population-based birth cohort study of 898 084 births using linked ART registry data and administrative data including birth registrations, medical services, pharmaceuticals, hospital admissions and deaths. Birth (a live or still birth of at least one baby of ≥400 g birthweight or ≥20 weeks’ gestation) was the unit of analysis in this study. Multiple births were considered as one birth in our analysis.

PARTICIPANTS/MATERIALS, SETTING, METHODS

This study included a total of 898 084 births (606 488 mothers) in New South Wales and the Australian Capital Territory, Australia 2009–2017. We calculated the prevalence of all categories of MAR-conceived births over the study period. Generalized estimating equations were used to examine the association between parental characteristics (parent’s age, parity, socio-economic status, maternal country of birth, remoteness of mother’s dwelling, pre-existing medical conditions, smoking, etc.) and ART and OI/IUI births relative to naturally conceived births.

MAIN RESULTS AND THE ROLE OF CHANCE

The proportion of MAR births increased from 5.1% of all births in 2009 to 6.7% in 2017, representing a 30% increase over the decade. The proportion of OI/IUI births remained stable at around 2% of all births, representing 32% of all MAR births. Over the study period, ART births conceived by frozen embryo-transfer increased nearly 3-fold. OI/IUI births conceived using clomiphene citrate decreased by 39%, while OI/IUI births conceived using letrozole increased 56-fold. Overall, there was a 55% increase over the study period in the number of ART-conceived births, rising to 56% of births to mothers aged 40 years and older. In 2017, almost one in six births (17.6%) to mothers aged 40 years and over were conceived using ART treatment. Conversely, the proportion of OI/IUI births was similar across different mother’s age groups and remained stable over the study period. ART children, but not OI/IUI children, were more likely to have parents who were socio-economically advantaged compared to naturally conceived children. For example, compared to naturally conceived births, ART births were 16% less likely to be born to mothers who live in the disadvantaged neighbourhoods after accounting for other covariates (adjusted relative risk (aRR): 0.84 [95% CI: 0.81–0.88]). ART- or OI/IUI-conceived children were 25% less likely to be born to immigrant mothers than births after natural conception (aRR: 0.75 [0.74–0.77]).

LIMITATIONS, REASONS FOR CAUTION

The social inequalities that we observed between the parents of children born using ART and naturally conceived children may not directly reflect disparities in accessing fertility care for individuals seeking treatment.

WIDER IMPLICATIONS OF THE FINDINGS

With the ubiquitous decline in fertility rates around the world and the increasing trend to delay childbearing, this population-based study enhances our understanding of the contribution of different types of MARs to population profiles among births in high-income countries. The parental socio-demographic characteristics of MAR-conceived children differ significantly from naturally conceived children and this highlights the importance of accounting for such differences in studies investigating the health and development of MAR-conceived children.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded through Australian National Health and Medical Research Council (NHMRC) grant: APP1127437. G.M.C. is an employee of The University of New South Wales (UNSW) and Director of the National Perinatal Epidemiology and Statistics Unit (NPESU), UNSW. The NPESU manages the Australian and New Zealand Assisted Reproduction Database with funding support from the Fertility Society of Australia and New Zealand. C.V. is an employee of The University of New South Wales (UNSW), Director of Clinical Research of IVFAustralia, Member of the Board of the Fertility Society of Australia and New Zealand, and Member of Research Committee of School of Women’s and Children’s Health, UNSW. C.V. reports grants from Australian National Health and Medical Research Council (NHMRC), and Merck KGaA. C.V. reports consulting fees, and payment or honoraria for lectures, presentations, speakers, bureaus, manuscript, writing or educational events or attending meeting or travel from Merck, Merck Sparpe & Dohme, Ferring, Gedon-Richter and Besins outside this submitted work. C.V. reported stock or stock options from Virtus Health Limited outside this submitted work. R.J.N. is an employee of The University of Adelaide, and Chair DSMC for natural therapies trial of The University of Hong Kong. R.J.N. reports grants from NHMRC. R.J.N. reports lecture fees and support for attending or travelling for lecture from Merck Serono which is outside this submitted work. L.R.J. is an employee of The UNSW and Foundation Director of the Centre for Big Data Research in Health at UNSW Sydney. L.R.J. reports grants from NHMRC. The other co-authors have no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Female dietary patterns and outcomes of in vitro fertilization (IVF): a systematic literature review

Background

Infertility affects up to 15% of couples. In vitro fertilization (IVF) treatment has modest success rates and some factors associated with infertility and poor treatment outcomes are not modifiable. Several studies have assessed the association between female dietary patterns, a modifiable factor, and IVF outcomes with conflicting results. We performed a systematic literature review to identify female dietary patterns associated with IVF outcomes, evaluate the body of evidence for potential sources of heterogeneity and methodological challenges, and offer suggestions to minimize heterogeneity and bias in future studies.

Methods

We performed systematic literature searches in EMBASE, PubMed, CINAHL, and Cochrane Central Register of Controlled Trials for studies with a publication date up to March 2020. We excluded studies limited to women who were overweight or diagnosed with PCOS. We included studies that evaluated the outcome of pregnancy or live birth. We conducted an initial bias assessment using the SIGN 50 Methodology Checklist 3.

Results

We reviewed 3280 titles and/or titles and abstracts. Seven prospective cohort studies investigating nine dietary patterns fit the inclusion criteria. Higher adherence to the Mediterranean diet, a ‘profertility’ diet, or a Dutch ‘preconception’ diet was associated with pregnancy or live birth after IVF treatment in at least one study. However, causation cannot be assumed. Studies were potentially hindered by methodological challenges (misclassification of the exposure, left truncation, and lack of comprehensive control for confounding) with an associated risk of bias. Studies of the Mediterranean diet were highly heterogenous in findings, study population, and methods. Remaining dietary patterns have only been examined in single and relatively small studies.

Conclusions

Future studies with rigorous and more uniform methodologies are needed to assess the association between female dietary patterns and IVF outcomes. At the clinical level, findings from this review do not support recommending any single dietary pattern for the purpose of improving pregnancy or live birth rates in women undergoing IVF treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12937-021-00757-7.

A review of disparities in access to infertility care and treatment outcomes among Hispanic women

Hispanic women have lower rates of use of infertility services than non-Hispanic White women. There are many barriers that impede access to infertility care including economic, geographic, cultural, and societal factors and there are disparities in treatment outcomes. Hispanic women are less likely to seek infertility care than non-Hispanic White women and even after infertility evaluation, Hispanic women are less likely to receive treatment for their infertility. Lower use of infertility treatments among Hispanic women is unlikely to be driven solely by economic factors. There is disappointingly little data on in-vitro fertilization treatment outcomes including the population of Hispanic women, and existing data has yielded conflicting results. Incomplete and variable reporting of race data across clinics raises the potential for misclassification bias and invalid study conclusions. Addressing disparities in access to reproductive medicine in the Hispanic population will required a multifaceted approach including expanded insurance coverage, improved education for both patients and providers, and additional research on barriers to care.

Impact of Mode of Conception on Early Pregnancy Human Chorionic Gonadotropin Rise and Birthweight

Objective

To assess whether the mode of conception and embryo biopsy impact first-trimester human chorionic gonadotropin (hCG) dynamics and subsequent risk of small for gestational age (SGA) or large for gestational age (LGA).

Design

Retrospective cohort study.

Setting

University fertility center.

Patient(s)

Six hundred-two pregnant patients with singleton live births.

Intervention(s)

Serial serum hCG measurements were obtained between 10 and 28 days postconception to determine the within-woman rate of change in hCG (slope) by mode of conception (unassisted pregnancy, fresh embryo transfer (ET), frozen ET, and frozen ET following preimplantation genetic testing for aneuploidy (PGT-A).

Main Outcome Measure(s)

Primary outcomes included birth weight, SGA, and LGA.

Result(s)

Mode of conception is not independently associated with birth weight, SGA, or LGA. Mediation analysis revealed an expected one-day increase in log-transformed hCG varied by mode of conception: unassisted (0.41), fresh ET (0.39), frozen ET (0.42), PGT-A (0.44). Human chorionic gonadotropin rise has a positive effect on birth weight (55 g per SD increase in hCG slope) and is associated with SGA (odds ratio, 0.65), but not with LGA (odds ratio, 1.18).

Conclusion(s)

Human chorionic gonadotropin rise is an important mediator of the mode of conception/birth weight relationship. Preimplantation genetic testing for aneuploidy has the highest rate of hCG rise, followed by frozen ET, unassisted, and fresh ET. Faster rise is associated with higher birth weight and lower risk of SGA but does not impact LGA risk. Importantly, PGT-A does not increase the risk of extreme birth weight relative to other modes of conception evaluated.

Body mass index, not race, may be associated with an alteration in early embryo morphokinetics during in vitro fertilization

OBJECTIVE

To assess the relationship between maternal body mass index (BMI) and embryo morphokinetics on time-lapse microscopy (TLM).

DESIGN

Retrospective cohort study.

METHODS

All IVF cycles between June 2015 and April 2017 were reviewed. Female BMI prior to egg retrieval was collected through chart review. BMI (kg/m2) classification included underweight (< 18.5), normal weight (18.5-25), overweight (25-30), and obese (≥ 30). Embryos' morphokinetic parameters were assessed with TLM and included time to syngamy, 2-cell, 3-cell, 4-cell, and 8-cell. A generalized linear mixed model was used to control for potential confounders and multiple embryos resulting from a single IVF cycle.

RESULTS

A total of 2150 embryos from 589 IVF cycles were reviewed and included in the analysis. Classification based on BMI was as follows: underweight (N = 56), normal weight (N = 1252), overweight (N = 502), and obese (N = 340). After adjusting for race and use of intracytoplasmic sperm injection, the mean time to the 8-cell stage in the underweight group was 4.3 (95% CI: - 8.31, - 0.21) h less than in the normal weight group (P = 0.025) and 4.6 (95% CI: - 8.8, - 0.21) h less than in the obese group (p = 0.022). No significant difference was noted between race and TLM after controlling for possible confounders.

CONCLUSIONS

Embryos from underweight women were demonstrated to have a faster time to the 8-cell stage than normal weight or obese women. No significant difference was noted for race. This study demonstrates that weight can be a factor contributing to embryo development as observed with TLM.

An mHealth App to Support Fertility Patients Navigating the World of Infertility (Infotility): Development and Usability Study

Background

The experience of infertility and its treatment engenders considerable stress and is often described as an emotional rollercoaster. A mobile health (mHealth) app may be a novel solution to address the psychoeducational and psychosocial support needs of fertility patients because of its potential to reduce stress and increase patient empowerment. There are a few fertility-related apps that provide information and support to both men and women undergoing fertility treatment; however, none have documented their development and evaluation process.

Objective

This study aims to describe the development and evaluation process of a bilingual mHealth app, Infotility, designed to meet the psychoeducational and psychosocial support needs of men and women undergoing fertility treatment.

Methods

To develop the Infotility app, we adhered to the Medical Research Council guidelines for the development and evaluation of complex interventions. First, we conducted literature reviews and needs assessment surveys of fertility patients and health care providers who informed the content and design of the app. Second, we tested the intervention with a small group of end users who provided feedback on the design and appropriateness of the app’s content. Third, we evaluated the uptake and usability of the app using a pre-post study design. Finally, we updated the app’s content based on participants’ feedback and searched for partners to disseminate the app to the broader public.

Results

This study is the first to describe the development and evaluation process of an mHealth app for men and women undergoing fertility treatment. The app met its goal in providing fertility patients with a clinician-approved, portable resource for reliable information about medical and psychosocial aspects of infertility and its treatments and a confidential peer support forum monitored by trained peer supporters. Participants rated the engagement, functionality, information, and esthetics of the app positively, with an overall app quality mean score of 3.75 (SD 0.53) and a star rating of 3.43 (SD 0.75), with a total possible score and star rating of 5.00.

Conclusions

By documenting the systematic development and evaluation of the mHealth app for men and women undergoing fertility treatment, this paper can facilitate the replication of the study intervention and the development of similar mHealth apps.

Tubal Factor Infertility, In Vitro Fertilization, and Racial Disparities: A Retrospective Cohort in Two US Clinics

BACKGROUND

Nearly 14% of US women report any lifetime infertility which is associated with health care costs and psychosocial consequences. Tubal factor infertility (TFI) often occurs as a result of sexually transmitted diseases and subsequent pelvic inflammatory disease. We sought to evaluate for and describe potential racial disparities in TFI and in vitro fertilization (IVF) prevalence.

METHODS

Records of women aged 19 to 42 years in our retrospective cohort from 2 US infertility clinics were reviewed. We calculated TFI prevalence, IVF initiation prevalence, and prevalence ratios (PRs), with 95% confidence intervals (CIs) for each estimate, overall and by race.

RESULTS

Among 660 infertile women, 110 (16.7%; 95% CI, 13.8-19.5%) had TFI which was higher in Black compared with White women (30.3% [33/109] vs 13.9% [68/489]; PR, 2.2 [95% CI, 1.5-3.1]). For women with TFI, IVF was offered to similar proportions of women by race (51.5% [17/33] vs 52.9% [36/68] for Black vs White women); however, fewer Black than White women with TFI started IVF (6.7% [1/15] vs 31.0% [9/29]; PR, 0.2 [95% CI, 0-1.0]), although the difference was not statistically different.

CONCLUSIONS

Tubal factor infertility prevalence was 2-fold higher among Black than White women seeking care for infertility. Among women with TFI, data suggested a lower likelihood of Black women starting IVF than White women. Improved sexually transmitted disease prevention and treatment might ameliorate disparities in TFI.

Reproductive endocrinologists' knowledge and attitudes in the identification of intimate partner violence

OBJECTIVE

To assess reproductive endocrinologists' attitudes, beliefs, knowledge, and experiences with intimate partner violence (IPV).

DESIGN

Cross-sectional survey of US reproductive endocrinologists.

SETTING

The survey was disseminated via both direct mail and e-mail to a voluntary, semirandomized US national sample of reproductive endocrinologists. We randomly selected a maximum of six clinics per state using the Centers for Disease Control and Prevention Fertility Clinic Success Rates Report.

PATIENT(S)

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURES

Clinician perceptions and knowledge regarding IPV and its relevance to the infertility setting.

RESULTS

A total of 95 reproductive endocrinology and infertility physicians practicing in either academic or private clinics in the United States completed the survey with an overall response rate of 46% (95/200). General knowledge of IPV was good among respondents. Intimate partner violence assessment was very relevant among 39% (37/95) of respondents and possibly relevant among 56% (53/95) of respondents. A history of IPV awareness training was associated with a decreased frequency of reported barriers, including fewer perceived time constraints, decreased knowledge regarding IPV community resources, and less discomfort asking about IPV. Most respondents estimated the prevalence of IPV in their practice to be rare (≤1%). However, 33% (31/95) reported identifying between one and five active victims of IPV over the prior year, and 63% (60/95) reported identifying a victim of IPV throughout their careers. Only 17% (16/95) of respondents were certain that their clinic had guidelines for detection or management of IPV.

CONCLUSION

Reproductive endocrinology and infertility physicians would benefit from education and training in IPV to enable them to better identify and assist patients who are victims of IPV.

Racial and Ethnic Disparities in Fertility Awareness Among Reproductive-Aged Women

Background: Despite the rising prevalence of infertility, studies have indicated that in the United States fertility awareness remains low. No published study to date, however, has investigated the impact of any racial or ethnic disparities in fertility awareness. Materials and Methods: We conducted a cross-sectional survey of people self-identifying as female, aged 18-45 years, via Amazon Mechanical Turk in August 2020. The study was approved by the institutional review board at the University of Colorado. The survey consisted of demographic questions and a validated questionnaire, the Fertility and Infertility Treatment Knowledge Score (FIT-KS). Participants were classified as non-Hispanic White (NHW) or "Minority" race/ethnicity. Results: A total of 476 women completed the survey, 405 of which were included in analysis. Of those, 54.6% self-identified as NHW and 45.4% were in the Minority group. The median FIT-KS was 51.7% (16 items answered correctly). The Minority group scored significantly lower than the NHW participants overall (58.6% vs. 48.3%, p < 0.001) and in all three subscales (p < 0.05). The Minority group was significantly more likely to underestimate the rate of miscarriage (47.3% vs. 32.6%, p = 0.003) and had a lower awareness of risk factors that can impact fertility including smoking (88.7% vs. 71.6%, p < 0.001), obesity (90.5% vs. 70.5%, p < 0.001), and/or a history of gonorrhea/chlamydia infection (83.7% vs. 64.7%, p < 0.001). Conclusions: Minority women appear to have a lower fertility awareness than their NHW counterparts. Addressing these disparities and improving fertility education in diverse communities may lead to a reduction in clinically significant infertility disparities.

The pipeline problem: barriers to access of Black patients and providers in reproductive medicine

The demographics of the United States are rapidly changing, and our health care workforce is not keeping pace with the population trends. The American Society for Reproductive Medicine (formerly The American Fertility Society) recognizes the need to increase diversity and is committed to promoting diversity across our membership and leadership as well as promoting equitable quality reproductive care to all patients. In the fall of 2020, the American Society for Reproductive Medicine convened a Diversity, Equity, and Inclusion Task Force to evaluate and make recommendations on the basis of findings to increase diversity to achieve equity and inclusion of reproductive and infertility services for all women. This article focuses on specific barriers that Black or African American patients face in accessing quality care and that provider's face in training and inclusion in reproductive medicine. Multiple publications have confirmed an improvement in health outcome when there is congruence between the patient and the provider. There is a stark contrast between the racial and ethnic diversity of our providers and other support personnel compared with that of our patients. Despite our best intent to minimize the effects of implicit and explicit bias, mistrust and misunderstandings when there is discordance between patients and providers negatively impacts care. To increase provider diversity, it is crucial that we prioritize pipeline programs that recruit and support underrepresented minority in medicine physicians. Specific recommendations are made to increase diversity in the pipeline to improve patient access to culturally competent quality reproductive medicine care with optimal outcomes.

Disparities in access to effective treatment for infertility in the United States: an Ethics Committee opinion

In the United States, economic, racial, ethnic, geographic, and other disparities prevent access to fertility treatment and affect treatment outcomes. This opinion examines the factors that contribute to these disparities, proposes actions to address them, and replaces the document of the same name, last published in 2015.

Health disparities of African Americans in reproductive medicine

The first paper describing an association between African American race, infertility prevalence, and outcomes of fertility treatments was published more than 20 years ago, calling initial attention to differences in how infertility is experienced, diagnosed, and managed in African Americans. Since that initial publication, multiple other studies have explored African American race and its association with elements of the fertility spectrum-disparities that have been durable over time. The goal of this review is to provide an overview of the evolution of aspects of this research focusing on the outcomes of infertility treatments and barriers to access. A consideration of the system-based practice issues that interface with timely fertility evaluation and treatment in ways that challenge reproductive health equity will be presented.

Risk of infertility in female adolescents and young adults with cancer: a population-based cohort study

STUDY QUESTION

Do female adolescents and young adults (AYAs) with cancer have a higher risk of subsequent infertility diagnosis than AYAs without cancer?

SUMMARY ANSWER

Female AYAs with breast, hematological, thyroid and melanoma cancer have a higher risk of subsequent infertility diagnosis.

WHAT IS KNOWN ALREADY

Cancer therapies have improved substantially, leading to dramatic increases in survival. As survival improves, there is an increasing emphasis on optimizing the quality of life among cancer survivors. Many cancer therapies increase the risk of infertility, but we lack population-based studies that quantify the risk of subsequent infertility diagnosis in female AYAs with non-gynecological cancers. The literature is limited to population-based studies comparing pregnancy or birth rates after cancer against unexposed women, or smaller studies using markers of the ovarian reserve as a proxy of infertility among female survivors of cancer.

STUDY DESIGN, SIZE, DURATION

We conducted a population-based cohort study using universal health care databases in the province of Ontario, Canada. Using data from the Ontario Cancer Registry, we identified all women 15-39 years of age diagnosed with the most common cancers in AYAs (brain, breast, colorectal, leukemia, Hodgkin lymphoma, non-Hodgkin lymphoma, thyroid and melanoma) from 1992 to 2011 who lived at least 5 years recurrence-free (Exposed, n = 14,316). Women with a tubal ligation, bilateral oophorectomy or hysterectomy previous to their cancer diagnosis were excluded. We matched each exposed woman by age, census subdivision, and parity to five randomly selected unexposed women (n = 60,975) and followed subjects until 31 December 2016.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Infertility diagnosis after 1 year of cancer was identified using information on physician billing codes through the Ontario Health Insurance Plan database (ICD-9 628). Modified Poisson regression models were used to assess the risk of infertility diagnosis (relative risk, RR) adjusted for income quintile and further stratified by parity at the time of cancer diagnosis (nulliparous and parous).

MAIN RESULTS AND THE ROLE OF CHANCE

Mean age at cancer diagnosis was 31.4 years. Overall, the proportion of infertility diagnosis was higher in cancer survivors compared to unexposed women. Mean age of infertility diagnosis was similar among cancer survivors and unexposed women (34.8 years and 34.9 years, respectively). The overall risk of infertility diagnosis was higher in cancer survivors (RR 1.30; 95% CI 1.23-1.37). Differences in infertility risk varied by type of cancer. Survivors of breast cancer (RR 1.46; 95% CI 1.30-1.65), leukemia (RR 1.56; 95% CI 1.09-2.22), Hodgkin lymphoma (RR 1.49; 95% CI 1.28-1.74), non-Hodgkin lymphoma (RR 1.42; 95% CI 1.14, 1.76), thyroid cancer (RR 1.20; 95% CI 1.10-1.30) and melanoma (RR 1.17; 95% CI 1.01, 1.35) had a higher risk of infertility diagnosis compared to women without cancer. After stratification by parity, the association remained in nulliparous women survivors of breast cancer, leukemia, lymphoma and melanoma, whereas it was attenuated in parous women. In survivors of thyroid cancer, the association remained statistically significant in both nulliparous and parous women. In survivors of brain or colorectal cancer, the association was not significant, overall or after stratification by parity.

LIMITATIONS, REASONS FOR CAUTION

Non-biological factors that may influence the likelihood of seeking a fertility assessment may not be captured in administrative databases. The effects of additional risk factors, including cancer treatment, which may modify the associations, need to be assessed in future studies.

WIDER IMPLICATIONS OF THE FINDINGS

Reproductive health surveillance in female AYAs with cancer is a priority, especially those with breast cancer, leukemia and lymphoma. Our finding of a potential effects of thyroid cancer (subject to over-diagnosis) and, to a lesser extent, melanoma need to be further studied, and, if an effect is confirmed, possible mechanisms need to be elucidated.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was provided by the Faculty of Health Sciences and Department of Obstetrics and Gynecology, Queen's University. There are no competing interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

Infertility in the Midwest: perceptions and attitudes of current treatment

BACKGROUND

Although infertility affects an estimated 6.1 million individuals in the United States, only half of those individuals seek fertility treatment and the majority of those patients are White and of high socioeconomic status. Research has shown that insurance mandates are not enough to ensure equal access. Many workplaces, schools, and medical education programs have made efforts in recent years to improve the cultural humility of providers in efforts to engage more racially and economically underrepresented groups in medical care. However, these efforts have not been assessed on a population of patients receiving fertility care, an experience that is uniquely shaped by individual social, cultural, and economic factors.

OBJECTIVE

This study aimed to better understand the racial, cultural, economic, and religious factors that impact patient experiences obtaining fertility care.

STUDY DESIGN

A cross-sectional self-administered survey was administered at an academic fertility center in Chicago, Illinois. Of 5000 consecutive fertility care patients, 1460 completed the survey and were included in the study sample. No interventions were used. Descriptive univariate frequencies and percentages were calculated to summarize sociodemographic and other relevant patient characteristics (eg, race or ethnicity, age, household income, religious affiliation, insurance coverage). Rates of endorsing perceived physician cultural competency were compared among demographic subgroups using Pearson chi-squared tests with 2-sided P<.05 indicative of statistical significance. To identify the key determinants of patient-reported worry regarding 9 different fertility treatment outcomes and related concerns, a series of multiple logistic regression models were fit to examine factors associated with patient report of being "very worried" or "extremely worried."

RESULTS

Members of our sample (N=1460) were between 20 and 58 years of age (mean_adjusted, 36.2; standard deviation, 4.4). Among Black participants, 42.3% reported that their physician does not understand their cultural background compared with 16.5% of White participants (P<.0001). Participants who identified as Latinx were significantly more likely than White participants to report being very/extremely worried about side effects of treatment, a miscarriage, ectopic pregnancies, and birth defects (P<.05, P=.02, P=.002, P=.001, respectively). Individuals who identify as Hindu were nearly 4 times more likely to report being very/extremely worried about experiencing an ectopic pregnancy than nonreligious participants (P<.0002). Respondents most strongly identified the biology or physiology of the couple (mean_adjusted, 21.6; confidence interval, 20.4-22.7) and timing or age (mean_adjusted, 27.8; confidence interval, 26.5-29.1) as being associated with fertility. Overall, respondents most strongly disagreed that the ability to bear children rests upon God's will (mean_adjusted, 65.4; confidence interval, 63.7-67.1), which differed most significantly by race (P<.0001) and religion (P<.0001).

CONCLUSION

Of the patient characteristics investigated, racial and ethnic subgroups showed the greatest degree of variation in regard to worries and concerns surrounding the experience of fertility treatment. Our findings emphasize a need for improved cultural humility on behalf of physicians, in addition to affordable psychological support for all patients seeking fertility care.

We are here for you: infertility clinic communication during the first wave of the COVID-19 pandemic

Purpose

To study how SART-member fertility clinics communicated via clinic websites during the first wave of the COVID-19 pandemic following publication of ASRM COVID-19 Task Force recommendations.

Methods

SART-member fertility clinic websites were systematically surveyed for the presence of an REI-specific COVID-19 message (REI-CM) and analyzed for their adherence to ASRM guidance.

Results

Of the 381 active clinic websites, 249 (65.3%) had REI-specific COVID messaging. The presence of REI-CM was more common in private than in academic practices (73% vs 38%, p < 0.001) and with increasing practice volume: 38% of clinics with < 200 annual cycles vs 91% of clinics with > 1000 cycles (p < 0.001). Adherence to ASRM guidance was more common in academic than in private practices (54% vs 31%, p = 0.02). Additionally, 9% of REI-CM (n = 23) announced continued treatment regardless of a patient’s clinical urgency. This messaging was more common in groups doing > 1000 cycles a year (18%, p = 0.009). Clinics treating all-comers were less likely to cite ASRM than other clinics (41% vs 62%, p = 0.045). However, 75% (n = 14) cited COVID-19 guidance from WHO, CDC, and state and local governments.

Conclusions

Clinic response to ASRM recommendations during the first wave of COVID-19 pandemic was heterogeneous. Although academic practices were more likely to follow ASRM guidance, there was a lower extent of patient-facing messaging among academic practices than private clinics. In event of further escalations of this and future pandemics, clinics can learn from experiences to provide clear messaging to patients.