The burden of very early dropout in infertility care: a nationwide population-based cohort study

STUDY QUESTION

What is the frequency and the associated factors of very early dropout following unsuccessful clomiphene citrate (CC)/gonadotropin treatment in the context of full coverage of treatment cost.

SUMMARY ANSWER

Despite free treatment, almost one in four women had a very early dropout following unsuccessful CC/gonadotropin treatment, with patients below the poverty line being more likely to drop out early.

WHAT IS KNOWN ALREADY

Success of infertility care is tarnished by very high dropout rates. Infertility care dropout has been considered as resulting principally from financial barriers because of the high cost of treatment. Nearly all previous work addressed dropout following IVF/ICSI. Factors associated with dropout following CC/gonadotropins may be different and also need to be investigated.

STUDY DESIGN, SIZE, DURATION

Nationwide population-based cohort study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Using the French national health insurance and hospital databases, we included in the cohort 27 416 women aged 18-49 years unsuccessfully treated with CC/gonadotropins in 2017. The main outcome was very early dropout, defined as discontinuation of all infertility treatment after unsuccessful treatment for 1-3 months. Very early treatment dropout was analysed by multivariate logistic regression.

MAIN RESULTS AND THE ROLE OF CHANCE

Among women unsuccessfully treated with CC/gonadotropins, 22% dropped out of infertility care within 3 months. In multivariate analysis, higher early dropout following unsuccessful CC/gonadotropin treatment was associated with older and younger ages (≥35 and <25 years), being below the poverty line, being treated with CC prescribed by a general practitioner and lack of infertility tests or monitoring.

LIMITATIONS, REASONS FOR CAUTION

This study is based on health administrative data that do not include reasons for dropout and record only a limited amount of information. It is thus not possible to analyse the reason for early dropout.

WIDER IMPLICATIONS OF THE FINDINGS

Despite full coverage of all infertility treatment, women under the poverty line have a higher risk of very early dropout following unsuccessful CC/gonadotropin treatment. Better understanding is needed of the non-financial barriers and difficulties faced by these patients. To address disparities in infertility treatment, practitioner training could be reinforced to adapt to patients from different social and cultural backgrounds.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the ANR StimHo project, grant ANR-17-CE36-0011-01 from the French Agence Nationale de la Recherche. The authors have no conflict of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

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.

Analysis of peer reviewers' response to invitations by gender and geographical region: cohort study of manuscripts reviewed at 21 biomedical journals before and during covid-19 pandemic

OBJECTIVES

To describe gender and geographical inequalities in invitations to review and the response to these invitations and to assess whether inequalities increased during the covid-19 pandemic.

DESIGN

Retrospective cohort study.

SETTING

19 specialist medical journals and two large general medical journals from BMJ Publishing Group.

POPULATION

Reviewers invited to review manuscripts submitted between 1 January 2018 and 31 May 2021. The cohort was followed up to 28 February 2022.

MAIN OUTCOME MEASURES

Reviewer's agreement to review.

RESULTS

A total of 257 025 reviewers were invited (38.6% (88 454/228 869) women), and 90 467 (35.2%) agreed to review. Invited reviewers were mainly (217 682; 84.7%) affiliated with high income countries: Europe (122 414; 47.6%), North America (66 931; 26.0%), Africa (25 735; 10.0%), Asia (22 693; 8.8%), Oceania (16 175; 6.3%), and South America (3076; 1.2%). Independent factors associated with agreement to review were gender (odds ratio 0.89, 95% confidence interval 0.87 to 0.92, for women compared with men), geographical affiliation (2.89, 2.73 to 3.06, for Asia; 3.32, 2.94 to 3.75 for South America; 1.35, 1.27 to 1.43, for Oceania; and 0.35, 0.33 to 0.37, for Africa compared with Europe), and country income (0.47, 0.45 to 0.49, for upper middle income; 5.12, 4.67 to 5.61, for lower middle income; and 4.66, 3.79 to 5.73, for low income compared with high income country). Agreement was also independently associated with editor's gender (0.96, 0.93 to 0.99, for women compared with men), last author's geographical affiliation (0.80, 0.78 to 0.83, for Asia; 0.89, 0.85 to 0.94, for Oceania compared with Europe), impact factor (1.78, 1.27 to 2.50, for >10 compared with <5), and type of peer review process (0.52, 0.35 to 0.77, for open compared with anonymised). During the first and second phases of the pandemic, agreement was lower than in the pre-pandemic period (P<0.001). The interaction between time periods and covid-19 related topic and reviewer's gender was non-significant. However, significant interaction was found between time periods and covid-19 related topic and reviewer's geographical affiliation.

CONCLUSIONS

To reduce bias and improve diversity, editors need to identify and implement effective strategies and continually evaluate progress against these to ensure that more women and researchers from upper middle income and low income countries are involved in review.

Female authorship of covid-19 research in manuscripts submitted to 11 biomedical journals: cross sectional study

OBJECTIVE

To describe prominent authorship positions held by women and the overall percentage of women co-authoring manuscripts submitted during the covid-19 pandemic compared with the previous two years.

DESIGN

Cross sectional study.

SETTING

Nine specialist and two large general medical journals.

POPULATION

Authors of research manuscripts submitted between 1 January 2018 and 31 May 2021.

MAIN OUTCOME MEASURES

Primary outcome: first author's gender.

SECONDARY OUTCOMES

last and corresponding authors' gender; number (percentage) of women on authorship byline in "pre-pandemic" period (1 January 2018 to 31 December 2019) and in "covid-19" and "non-covid-19" manuscripts during pandemic.

RESULTS

A total of 63 259 manuscripts were included. The number of female first, last, and corresponding authors respectively were 1313 (37.1%), 996 (27.9%), and 1119 (31.1%) for covid-19 manuscripts (lowest values in Jan-May 2020: 230 (29.4%), 165 (21.1%), and 185 (22.9%)), compared with 8583 (44.9%), 6118 (31.2%), and 7273 (37.3%) for pandemic non-covid-19 manuscripts and 12 724 (46.0%), 8923 (31.4%), and 10 981 (38.9%) for pre-pandemic manuscripts. The adjusted odds ratio of having a female first author in covid-19 manuscripts was <1.00 in all groups (P<0.001) compared with pre-pandemic (lowest in Jan-May 2020: 0.55, 98.75% confidence interval 0.43 to 0.70). The adjusted odds ratio of having a woman as last or corresponding author was significantly lower for covid-19 manuscripts in all time periods (except for the two most recent periods for last author) compared with pre-pandemic (lowest values in Jan-May 2020: 0.74 (0.57 to 0.97) for last and 0.61 (0.49 to 0.77) for corresponding author). The odds ratios for pandemic non-covid-19 manuscripts were not significantly different compared with pre-pandemic manuscripts. The median percentage of female authors on the byline was lower for covid-19 manuscripts (28.6% in Jan-May 2020) compared with pre-pandemic (36.4%) and non-covid-19 pandemic manuscripts (33.3% in Jan-May 2020). Gender disparities in all prominent authorship positions and the proportion of women authors on the byline narrowed in the most recent period (Feb-May 2021) compared with the early pandemic period (Jan-May 2020) and were very similar to values observed for pre-pandemic manuscripts.

CONCLUSIONS

Women have been underrepresented as co-authors and in prominent authorship positions in covid-19 research, and this gender disparity needs to be corrected by those involved in academic promotion and awarding of research grants. Women attained some prominent authorship positions equally or more frequently than before the pandemic on non-covid-19 related manuscripts submitted at some time points during the pandemic.

577Inequalities in access to in vitro fertilisation treatment in France

Background

In vitro fertilisation (IVF) treatment is one of the most expensive infertility treatments. Cost has been described as a substantial barrier to access. In France all infertility treatments, including IVF, are fully reimbursed, but are there other barriers to access?

Methods

Based on the French national health insurance database that exhaustively records reimbursed healthcare, this cohort study included all women aged 18–49 years unsuccessfully treated with ovarian induction (first-line infertility treatment) between January–August 2016. Outcome was IVF access within 24 months of starting first-line treatment. Univariate and multivariate regressions explored age, disadvantaged social status, driving time to nearest IVF centre, and deprivation index of area of residence.

Results

Over 20,000 women unsuccessfully received first-line treatment. Almost 80% did not access IVF within 24 months.

After age 34, probability of access decreased. Disadvantaged social status and living in a disadvantaged area were associated with lower probability of accessing IVF. Driving time to the nearest IVF centre was not significantly associated with access.

Conclusions

Socio-economic barriers to access IVF exist despite full treatment reimbursement in France. To reduce health inequalities, we need to better understand the nature and patterns of these barriers among less socially advantaged people.

Key messages

After failure of first-line infertility treatment, only 20% of women access IVF although it is fully reimbursed in France.

Age, but most importantly socio-economic status, is a key determinant of access to IVF treatment.

Distance from nearest IVF centre does not appear significant in explaining access to treatment in France.

Infertility Treatment in France, 2008-2017: A Challenge of Growing Treatment Needs at Older Ages

Objectives. To measure trends in infertility treatment use between 2008 and 2017 in France using data from the national health insurance system.Methods. Between 2008 and 2017, we observed a representative national sample of nearly 1% of all women aged 20 to 49 years who were affiliated with the main health insurance scheme in France (more than 100 000 women observed each year). We exhaustively recorded all health care reimbursed to these women.Results. Among women aged 20 to 49 years, 1.25% were treated for infertility each year. Logistic regression analysis showed a significant interaction between age and year of treatment use (P < .001). Over the decade, infertility treatment use increased by 23.9% among women aged 34 years or older, whereas among women younger than 34 years there was a nonsignificant variation.Conclusions. Women aged 34 years or older were increasingly treated for infertility between 2008 and 2017.Public Health Implications. Treatment efficiency decreases strongly with a woman's age, presenting a challenge for medical infertility care.