Proceedings from the conference on Reproductive Problems in Women of Color

Moving toward Narrowing the United States Gap in Assisted Reproductive Technology (ART) Racial and Ethnic Disparities in the Next Decade

The Disparities in Assisted Reproductive Technology (DART) hypothesis, initially described in 2013 and further modified in 2022, is a conceptual framework to examine the scope and depth of underlying contributing factors to the differences in access and treatment outcomes for racial and ethnic minorities undergoing ART in the United States. In 2009, the World Health Organization defined infertility as a disease of the reproductive system, thus recognizing it as a medical problem warranting treatment. Now, infertility care is largely recognized as a human right. However, disparities in Reproductive Endocrinology and Infertility (REI) care in the US persist today. While several studies and review articles have suggested possible solutions to racial and ethnic disparities in access and outcomes in ART, few have accounted for and addressed the multiple complex factors contributing to these disparities on a systemic level. This review aims to acknowledge and address the myriad of contributing factors through the DART hypothesis which converge in racial/ethnic disparities in ART and considers possible solutions to effect large scale societal change by narrowing these gaps within the next decade.

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.

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.

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.

Disparities in access to fertility care: who's in and who's out

Objective

To study the racial and socioeconomic characteristics of women seeking fertility care in a state with mandated insurance coverage for fertility testing and treatment.

Design

Cross-sectional, self-administered survey.

Setting

Academic fertility center in Illinois.

Patients

Of 5,000 consecutive fertility care patients, 1,460 completed the survey and were included in the study sample.

Interventions

None.

Main Outcome Measures

Details about demographic characteristics and health care access on the basis of patient race/ethnicity and socioeconomic status.

Results

The mean age of participants was 36.1 years; 75.5% were White, 10.2% Asian, 7.3% Black, 5.7% Latinx, and 1.3% Other. Most women had a bachelor's (35.5%) or master's degree (40.5%) and an annual household income of >$100,000 (81.5%). Black and Hispanic women traveled twice as far (median 10 miles) as White and Asian women (median 5 miles for both) for treatment. Black women (14.7%) were more likely to report that their race was a barrier to getting fertility treatment compared with White (0.0%), Hispanic (5.1%), and Asian (5.4%) women. Black and Hispanic women were approximately twice as likely to report income level (26.5% and 20.3%, respectively) and weight (7.8% and 8.9%, respectively) as barriers compared with White and Asian respondents.

Conclusions

Significant racial and socioeconomic disparities exist among fertility patients accessing care. Beyond providing all Americans with health insurance that covers fertility treatment, further research in the general population is needed to understand the complex social, cultural, racial, and economic factors that prohibit many individuals from accessing needed fertility care.

Decreased live births among women of Middle Eastern/North African ethnicity compared to Caucasian women

PURPOSE

The objective of this study is to determine if IVF outcome disparities exist among MENA women in the USA in comparison to a control group of Caucasian women.

METHODS

A retrospective cohort study comparing MENA (N = 190) and Caucasian (N = 200) women undergoing their first IVF cycle between 5/2006 and 5/2014 was carried out at an academically affiliated fertility practice. All MENA cycles during that time period undergoing IVF/ICSI using autologous embryos and blastocyst transfers were compared to a control group of Caucasian women.

RESULTS

MENA women were significantly younger (32.9 vs 34.5, P < 0.005) and had a lower BMI (25.2 vs 27.1, P < 0.001). Male factor infertility was higher among partners of MENA women (62 vs 50%, P < 0.05). MENA women experienced decreased live birth rates per blastocyst transfer compared to Caucasian women after controlling for age and BMI (OR 0.55, 95% CI 0.35-0.85 P = 0.007). The odds of a miscarriage were also significantly higher among MENA women (OR 2.55, 95% CI 1.04-6.27 P = 0.036).

CONCLUSION

Middle Eastern/North African women have worse IVF outcomes with decreased live birth rates per blastocyst transfer and increased miscarriage rates compared to Caucasian women.