Explaining disparities in treatment seeking: the case of infertility

The experience of infertility: a review of recent literature

About 10 years ago Greil published a review and critique of the literature on the socio-psychological impact of infertility. He found at the time that most scholars treated infertility as a medical condition with psychological consequences rather than as a socially constructed reality. This article examines research published since the last review. More studies now place infertility within larger social contexts and social scientific frameworks although clinical emphases persist. Methodological problems remain but important improvements are also evident. We identify two vigorous research traditions in the social scientific study of infertility. One tradition uses primarily quantitative techniques to study clinic patients in order to improve service delivery and to assess the need for psychological counselling. The other tradition uses primarily qualitative research to capture the experiences of infertile people in a sociocultural context. We conclude that more attention is now being paid to the ways in which the experience of infertility is shaped by social context. We call for continued progress in the development of a distinctly sociological approach to infertility and for the continued integration of the two research traditions identified here.

When do involuntarily infertile couples choose to seek medical help?

OBJECTIVE

To estimate the probability of medical consultation for infertility during the course of a pregnancy attempt and to study its determinants.

DESIGN

Pregnancy-based retrospective telephone survey analyzed with a discrete time Cox model.

SETTING

Two rural counties in Brittany and Normandy, France.

PATIENT(S)

A random sample of 901 women from the general population aged 18-60 years reporting 1,460 pregnancy attempts resulting in a live birth between 1985 and 2000 (participation rate, 73%).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Probability of medical consultation for involuntary infertility cumulated over time.

RESULT(S)

The cumulative probability of medical consultation for involuntary infertility among nulligravid women was 45% after 12 months of involuntary infertility and 75% after 24 months. The probability of medical consultation at any time was half that for parous women (odds ratio 0.4, 95% confidence interval 0.2-0.6). More highly educated women were more likely to have sought medical help for infertility. Only 45% of women who had sought medical advice received infertility treatment.

CONCLUSION(S)

Our survival approach provides a description of infertility service use during the course of a pregnancy attempt, and confirms that parity and educational level are strong predictors of medical help-seeking behaviors.

Country of birth and hospitalization for pelvic inflammatory disease, ectopic pregnancy, endometriosis, and infertility: a nationwide study of 2 million women in Sweden

OBJECTIVE

To examine the association between country of birth and hospitalization for pelvic inflammatory disease (PID), ectopic pregnancy (EP), endometriosis, and infertility.

DESIGN

Follow-up study.

SETTING

Sweden.

PARTICIPANT(S)

A total of 2,170,177 women living in Sweden at some point between 1990 and 2004, categorized into 10 different groups according to country of birth.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Hospitalization for PID, EP, endometriosis, and infertility.

RESULTS

For PID and infertility, all groups of foreign-born women exhibited significantly increased risks compared with Swedish-born women. The highest risks of PID were found among women from southern Europe, Eritrea/Ethiopia/Somalia, and other African countries, whereas the highest risks of infertility were found among women from Middle Eastern countries, other Asian countries, and other African countries. Compared with PID and infertility, country of birth was less associated with endometriosis and EP, although some differences were found. All relative risks were adjusted for age, time period, and the women's socioeconomic status.

CONCLUSION(S)

Even in a country like Sweden, which offers publicly financed treatment for infertility, differences based on country of birth exist. Although data on partners' income were not available to us, it is possible that other factors besides socioeconomic factors are present in the etiology of female health problems related to infertility.

Human embryonic stem cell research, justice, and the problem of unequal biological access

In 2003, Ruth Faden and eighteen other colleagues argued that a "problem of unequal biological access" is likely to arise in access to therapies resulting from human embryonic stem cell research. They showed that unless deliberate steps are taken in the United States to ensure that the human embryonic stem cell lines available to researchers mirrors the genetic diversity of the general population, white Americans will likely receive the benefits of these therapies to the relative exclusion of minority ethnic groups. Over the past five years the problem of unequal biological access has not received much attention from politicians, bioethicists and even many researchers in the United States, in spite of the widely held belief in the country that there is an obligation to prevent and correct ethnic disparities in access to medical care. The purpose of this paper is to increase awareness of the problem of unequal biological access and of the need to do more than is currently being done to ensure that ethnic disparities in access to human embryonic stem cell-based therapies do not arise. Specifically, this paper explains why the problem of unequal biological access will likely arise in the United States in such a way that white Americans will disproportionately receive most of the benefits of the therapies resulting from human embryonic stem cell research. It also argues for why there is an obligation to prevent these ethnic disparities in access from happening and outlines four steps that need to be taken towards meeting this obligation.

In vitro fertilization availability and utilization in the United States: a study of demographic, social, and economic factors

OBJECTIVE

To characterize the demographic correlates of IVF availability and utilization.

DESIGN

Demographic analysis of public data.

SETTING

Each of the 50 states in the United States was used as a unit of analysis.

PATIENT(S)

Patients undergoing IVF, as demographically estimated.

INTERVENTION(S)

Publicly available data were collected through the Society for Assisted Reproductive Technology and the Centers for Disease Control. The US Census Bureau data were collected by using software available from the Centers for Disease Control.

MAIN OUTCOME MEASURE(S)

The number of physicians performing IVF and the number of IVF cycles per 100,000 reproductive-age women were used to estimate IVF availability and utilization.

RESULT(S)

In 2005, 1,031 providers performed 98,242 fresh IVF cycles in 430 centers. Overall availability was 2.5 IVF physicians per 100,000, and utilization was 236 IVF cycles per 100,000. Availability and utilization of IVF were highly correlated. Mean IVF availability and utilization were significantly higher in states with IVF insurance coverage. In adjusted analyses, IVF availability correlated positively with mandated insurance coverage, percentage of single persons, and median income. Utilization of IVF correlated with IVF availability, percentage urbanization, and percentage of individuals >or=25 years of age who had a bachelor's degree.

CONCLUSION(S)

Lower rates of IVF utilization in some states are correlated with a lack of insurance coverage and decreased availability of physicians providing this service.

Predictors of pregnancy and discontinuation of infertility services among women who received medical help to become pregnant, National Survey of Family Growth, 2002

OBJECTIVE

To determine demographic characteristics associated with pregnancy and, separately, discontinuation of infertility services when unsuccessful at achieving pregnancy, among a national sample of women who received infertility services.

DESIGN

Using a log-linear regression model, we examined associations with becoming pregnant among women who had received infertility services; and using a Cox proportional hazards model, we examined associations with earlier infertility service discontinuation.

SETTING

2002 National Survey of Family Growth, Cycle 6.

PARTICIPANT(S)

A total of 530 women aged 18-44 years in the 2002 National Survey of Family Growth who had received infertility services.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Relative risks for predictors of pregnancy after receiving infertility services; median time to discontinuation of infertility services; hazard ratios for predictors of earlier discontinuation of services.

RESULT(S)

Fifty-nine percent of respondents became pregnant while receiving infertility services, and 32% reported discontinuing infertility services before establishing a pregnancy. Women received infertility services for a median of 8 months; among those who discontinued services, more than half did so within 1 month. Among women who received infertility services, those who were white, nonsmokers, nulliparous, had insurance coverage, and received more than advice had a higher likelihood of pregnancy. Non-whites, parous women, and smokers discontinued infertility services earlier than others.

CONCLUSION(S)

Patients should be adequately counseled regarding modifiable behaviors and the range of services available before making decisions regarding their infertility.

Online psychoeducational support for infertile women: a randomized controlled trial

BACKGROUND

The study goal was to develop and test the effectiveness of a brief online education and support program for female infertility patients.

METHODS

A randomized-controlled trial was conducted. Using a Solomon-four group design, 190 female patients were recruited from three US fertility centers and were randomized into two experimental and two no-treatment control groups. The psychological outcomes assessed included infertility distress, infertility self-efficacy, decisional conflict, marital cohesion and coping style. Program dosage and satisfaction were also assessed at four weeks follow-up.

RESULTS

Women exposed to the online program significantly improved in the area of social concerns (P = 0.038) related to infertility distress, and felt more informed about a medical decision with which they were contending (P = 0.037). Trends were observed for decreased global stress(P = 0.10), sexual concerns (P = 0.059), distress related to child-free living (P = 0.063), increased infertility self-efficacy (P = 0.067) and decision making clarity (P = 0.079). A dosage response was observed in the experimental groups for women who spent >60 min online for decreased global stress (P = 0.028) and increased self efficacy (P = 0.024).

CONCLUSIONS

This evidence-based eHealth program for women experiencing infertility suggests that a web-based patient education intervention can have beneficial effects in several psychological domains and may be a cost effective resource for fertility practices.

Resource allocation of in vitro fertilization: a nationwide register-based cohort study

BACKGROUND

Infertility is common and in vitro fertilization (IVF) is a widely used treatment. In IVF the need increases and the effectiveness and appropriateness decrease by age. The purpose of this study was to describe allocation of resources for IVF by women's age, socioeconomic position, area of residence and treatment sector (public vs. private) and to discuss how fairly the IVF resources are allocated in Finland.

METHODS

Women who received IVF between 1996 and 1998 (N = 9175) were identified from the reimbursement records of the Social Insurance Institution (SII). Information on IVF women's background characteristics came from the Central Population Register and the SII, on treatment costs from IVF clinics and the SII, and on births from the Medical Birth Register. The main outcome measures were success of IVF by number of cycles and treated women, expenditures per IVF cycles, per women, per live-birth, and per treatment sector, and private and public expenditures. Expenditures were estimated from health care visits and costs.

RESULTS

During a mean period of 1.5 years, older women (women aged 40 or older) received 1.4 times more IVF treatment cycles than younger women (women aged below 30). The success rate decreased by age: from 22 live births per 100 cycles among younger women to 6 per 100 among older women. The mean cost of a live birth increased by age: compared to younger women, costs per born live birth of older women were 3-fold. Calculated by population, public expenditure was allocated most to young women and women from the highest socioeconomic position. Regional differences were not remarkable.

CONCLUSION

Children of older infertile women involve more expense due to the lower success rates of IVF. Socioeconomic differences suggest unfair resource allocation in Finland.

Incidence and complications of multiple gestation in Canada: proceedings of an expert meeting

This paper reports the proceedings of a consensus meeting on the incidence and complications of multiple gestation in Canada. In addition to background presentations about current and possible future practice in Canada, the expert panel also developed a set of consensus points. The need for infertility to be understood, and funded, as a healthcare problem was emphasized, along with recognition of the emotional impact of infertility. It was agreed that the goal of assisted reproduction treatment is the delivery of a single healthy infant and that even though many positive outcomes have resulted from twin or even triplet pregnancies, the potential risks associated with multiple pregnancy require that every effort be made to achieve this goal. The evidence shows that treatments other than IVF (such as superovulation and clomiphene citrate) contribute significantly to the incidence of multiple pregnancy. There is an urgent need for studies to understand better the usage and application of these other fertility technologies within Canada, as well as the non-financial barriers to treatment. The final consensus of the expert panel was that with adequate funding and good access to treatment, it will be possible to achieve the goal of reducing IVF-related multiple pregnancy rates in Canada by 50%.

Development and validation of the Infertility Self-Efficacy scale

OBJECTIVE

To develop and validate a scale of perceived self-efficacy for people coping with infertility treatment.

DESIGN

Self-efficacy scale development involved: [1] item generation with medical experts in reproductive health; [2] a principal components analysis with varimax rotation to identify underlying item components; [3] test-retest reliability and construct (convergent and discriminant) validity with infertility patients, who were administered the Infertility Self-Efficacy (ISE) scale with other measures; and [4] expert acceptability, as determined by reproductive health professionals.

SETTING

Recruitment at a fertility center, a national infertility organization, and medical trials web pages.

PATIENT(S)

A total of 213 participants (159 women; 54 men) with a diagnosis of infertility in the past 2 years were recruited for the various study phases.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Participants' infertility self-efficacy was assessed with an online assessment battery using the ISE scale; comparison mental health measures assessed current levels of fertility problem distress, perceived stress, and coping style. Reliability, validity, and component structure of the ISE was assessed.

RESULT(S)

Measurement development yielded a brief 16-item ISE scale that taps an infertility patient's perception about his or her ability to engage in a set of cognitive, emotional, and behavioral skills related to the medical treatment of infertility. The single component of "cognitive/affect regulation" suggests this core set of skills is relevant to successfully managing the experience of infertility. The ISE correlations with comparison mental health measures were as expected, suggesting good convergent and discriminant validity.

CONCLUSION(S)

The ISE scale appears to be a reliable and valid measure of an individual's self confidence in areas related to health promotion during infertility treatment. Assessing an infertility patients' self-efficacy with the ISE may be useful in clinical research and as a counseling tool to help guide patients in actively managing their fertility treatment.