Race-ethnicity and medical services for infertility: stratified reproduction in a population-based sample of U.S. women

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.

Pregnant racialised migrants and the ubiquitous border: The hostile environment as a technology of stratified reproduction

This article explores the impact of the 'hostile environment' on racialised migrant women's experiences of pregnancy and childbirth in England, arguing that the 'hostile environment' functions as a technology of 'stratified reproduction.' First coined by Shellee Colen, the concept of stratified reproduction describes the dynamic by which some individuals and groups may be supported in their reproductive activities, while others are disempowered and discouraged. This paper locates the stratified reproduction produced by the 'hostile environment' as intertwined with wider gendered and racialised discourses around British citizenship which have been 'designed to fail' racialised residents of the UK. Drawing on interviews with racialised migrant mothers in the north of England, this paper analyses how the proliferation and intensification of immigration controls interacts with gender, race, class, and other social regimes to differentially allocate the resources necessary for a safe and healthy pregnancy and childbirth, and how this is experienced materially by pregnant migrants.

Association between polycyclic aromatic hydrocarbons and infertility in U.S. women: National Health and Nutrition Examination Survey 2013-2016

Although there is a body of research indicating the potential impact of polycyclic aromatic hydrocarbons (PAHs) exposure on male infertility, the understanding of how PAH might affect female infertility is still limited. This study aimed to evaluate associations of PAHs, both individually and as a mixture, with female infertility using multiple logistic regression, Bayesian kernel machine regression (BKMR), and quantile g-computation (QGC) models based on data from the National Health and Nutrition Examination Survey (NHANES) 2013-2016. The study included 729 female participants. Multiple logistic regression results indicated that there was a significant association between the third tertile of 2-hydroxy fluorene (2-OHFLU) and female infertility, and the OR was 2.84 (95% CI: 1.24-6.53, P value = 0.015) compared with the first tertile after adjusting for the potential covariates. The BKMR model revealed a positive overall trend between mixed PAH exposure and female infertility, particularly when the mixture was at or above the 55th percentile, where 2-hydroxynaphthalene (2-OHNAP) and 1-hydroxypyrene (1-OHPYR) were the primary influences of the mixture. The univariate exposure-response function indicated positive associations between individual PAH exposure, specifically 2-OHNAP, 2-OHFLU, and 1-OHPYR, and female infertility. The QGC model also indicated a positive trend between exposure to a mixture of PAHs and female infertility, although it did not reach statistical significance (OR = 1.33, 95%CI: 0.86-2.07), with 1-OHPYR having the greatest positive effect on the outcome. This study suggested that exposure to PAHs may be associated with female infertility and further research is needed to consolidate and confirm these findings.

Identifying modifiable factors associated with psychological health in women experiencing infertility

This study assessed the relationship between modifiable psychological variables and depression, anxiety, and posttraumatic growth in women experiencing infertility. U.S. women (N = 457) who identified as experiencing infertility completed standardized self-report measures of mindfulness, self-compassion, positive affect, intolerance of uncertainty, relationship satisfaction, experiential avoidance, depression, anxiety, and posttraumatic growth. Clinical and demographic characteristics (age, duration trying to conceive, miscarriage, and childlessness) did not predict depression or anxiety. Lower positive affect and higher experiential avoidance were associated with depression and anxiety. Lower self-compassion was associated with depression; higher intolerance of uncertainty was associated with anxiety. There were indirect effects of mindfulness on anxiety and depression via these variables. Future research should explore whether intervening on these factors reduces depressive and anxiety symptoms. Promoting mindfulness may have beneficial effects on symptoms via its downstream effects on multiple coping variables. Counterintuitively, posttraumatic growth was associated with higher intolerance of uncertainty and experiential avoidance.

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.

Parental sociodemographics of medically assisted reproduction births in the United States: a dyadic population-level study

Objective

To study how men's and couples' sociodemographic characteristics predict the probability of having a birth conceived using medically assisted reproduction (MAR) in the United States.

Design

Population-based study.

Setting

Not applicable.

Patients

Men and women in the National Vital Statistics Birth certificate data from 2009 to 2019.

Intervention

None.

Main Outcome Measures

Proportion of MAR births out of total births by parental sociodemographic categories and probability of having a MAR birth.

Results

Between 2009 and 2019, the overall prevalence of MAR births among men was 1.81%. Fathers of children conceived using MAR tended to be older, higher educated, and white compared with fathers of naturally conceived children. During the period of 2009-2019, these sociodemographic profiles remained largely unchanged. Controlling for maternal age and birth order only partially reduced disparities by education and race. In 2019, highly educated fathers were 2.04 percentage points (95% confidence interval, 1.97-2.12) more likely to have a MAR-conceived birth than fathers with a low educational level, and black fathers were associated with a reduction in the probability of having an MAR-conceived child by - 1.07 percentage points (95% confidence interval, -1.11 to -1.04) compared with white fathers. The dyadic analysis using parents' education and race interactions revealed that partnering with someone of a higher educational level increases the likelihood of having a MAR birth, beyond what would be observed by considering only individual-level characteristics.

Conclusions

To comprehend the environment in which MAR-conceived children are born and raised, performing dyadic analyses that examine the characteristics of both partners is essential. The findings underscore the enduring presence of substantial social disparities in MAR use in the United States, with MAR-conceived children raised in environments of relative advantage, which may impact their future health and development.

Racial and ethnic disparities in assisted reproductive technology: a systematic review

There is emergent scientific literature examining the disparities in reproductive care of women in the United States. Reproduction is a basic human right and there are unique challenges that racial and ethnic minorities face in accessing fertility care and assisted reproductive technology. The identification of these disparities can aid in identifying areas for interventions to improve and resolve, the inequities that exist in providing care for minority populations. A literature search was performed using PubMed to identify articles with data specific to racial and ethnic differences in study populations as it related to infertility, access to care, and treatment outcomes. The following review and collection of articles provide a comprehensive overview of the disparities that exist, the factors that contribute to these disparities, and recommendations for how providers and health care systems may begin to resolve the gaps in equitable care.

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.

Association between Perfluoroalkyl and Polyfluoroalkyl Substances and Women's Infertility, NHANES 2013-2016

Perfluoroalkyl and polyfluoroalkyl substances (PFASs) are widely used in consumer products. However, the role of PFAS in infertility is still poorly understood. A total of 788 women from the 2013-2016 nationally representative NHANES were included to explore the association between PFAS exposure and self-reported infertility. Six PFAS, including PFDE, PFNA, PFHxS, n-PFOA, n-PFOS, and Sm-PFOS, were detected by online SPE-HPLC-TIS-MS/MS. We used the generalized linear regression model (GLM), generalized additive models (GAM), and Bayesian kernel machine regression (BKMR) to assess the single effects, non-linear relationships, and mixed effects on women's infertility, respectively. The prevalence of self-reported infertility was 15.54% in this study. In GLM, n-PFOA showed a negative association with self-reported infertility in women for the Q3 (OR: 0.396, 95% CI: 0.119, 0.788) and Q4 (OR: 0.380, 95% CI: 0.172-0.842) compared with Q1 (p for trend = 0.013). A negative trend was also observed in n-PFOS and ∑PFOS (p for trend < 0.05). In GAM, a non-linear relationship was revealed in Sm-PFOS, which exhibits a U-shaped relationship. The BKMR model indicated that there might be a joint effect between PFAS and women's infertility, to which PFNA contributed the highest effect (PIP = 0.435). Moreover, age stratification analysis showed a different dose-response curve in under and above 35 years old. Women under the age of 35 have a more noticeable U-shaped relationship with infertility. Therefore, the relatively low level of mixed PFAS exposure was negatively associated with self-reported infertility in women in general, and the impact of PFAS on infertility may vary among women of different age groups. Further studies are needed to determine the etiological relationship.

The interplay of race/ethnicity and education in fertility patterns

This study examines the interplay between race/ethnicity and educational attainment in shaping completed fertility in the United States for women born 1961-80. Using data from the National Survey of Family Growth, 2006-17, we apply multilevel, multiprocess hazard models to account for unobserved heterogeneity and to estimate (1) cohort total fertility rates, (2) parity progression ratios, and (3) parity-specific fertility timing, for non-Hispanic white, non-Hispanic Black, and Hispanic women by educational attainment. We find that compared with their white counterparts, fertility was higher among Black and Hispanic women with less than high school education. However, among college-educated women, fertility levels were lowest among Black women and highest among Hispanic women. The difference in fertility between college-educated Black and white women is driven mainly by the smaller proportion of Black mothers having second births. We find little evidence that the observed racial/ethnic disparities in fertility levels by educational attainment are driven by differences in fertility timing.

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.

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.

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.

At risk of reproductive disadvantage? Exploring fertility awareness among migrant women in Germany

This study examined awareness about fertility among immigrant women and non-migrants in Germany. The social relevance of infertility and fertility treatment is increasing in Western countries due to continually low overall birth rates, a high rate of childlessness, and a gap between the desired and actual numbers of children. While there is growing interest in infertility and reproductive medicine in general, previous studies have rarely included immigrant or ethnic minorities in Europe. This study investigated whether knowledge on the age-related fertility decline (ARFD) varies between migrant groups and the majority group, and the role of education. Working hypotheses were drawn from theoretical considerations on frameworks of migrant assimilation. The analysis was based on data collected in a social science pilot study on reproductive medicine, representative of the general population ('NeWiRe' 2014-2015). The sample included 962 women aged 18-50 years living in Germany. Approximately 81% of the sample were immigrants who originated from Turkey, Poland, the Balkan countries or countries of the (post-Soviet) Commonwealth of Independent States. While rather poor overall, knowledge on ARFD was found to be significantly lower in the migrant groups compared with the majority group. This minority-group disadvantage cannot be explained by sociodemographic or cultural variables. Future research should include minority groups in empirical studies on awareness about fertility in order to better understand the causes of this disadvantage, and the potential reproductive needs of migrants.

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.

Cultural health capital and the stratification of reproduction in Czech and Spanish egg donation markets

This article explores the ways that fertility clinics in the Czech Republic and Spain attract international fertility clients for fertility treatment involving egg donation. I draw upon a content analysis of 18 fertility clinics' advertising materials and 31 in-depth interviews with fertility professionals in the Czech Republic and Spain, and Canadian fertility travellers to show how clinics use cultural health capital (CHC) to persist as popular destination sites for fertility travellers. I argue that the use of evidence-based medicine and patient-centred care combined with bioracial discourses are strategies by which clinics create a culture of fertility care that is legible to white, middle-class, hetero travellers. My interviews with fertility patients who travelled to these sites show the ways in which CHC is interactional-I document how fertility travellers desire these specific practices that are both created for and marketed to them. By expanding the definition of CHC to show how fertility clinics market and fertility travellers expect a particular culture of fertility medicine, I elucidate the interactions between clinics and professionals that reinforce ideals of white motherhood and the stratification of reproduction.

Toward an Intersectional Psychological Science of Reproductive Norms: Generating Research Across the Natalism Spectrum

Pronatalism is the belief system that encourages parenthood and reproduction, supporting the notion that a woman’s value is rooted in her ability to give birth to and parent children. Pronatalist expectations are disproportionately applied to high-status women in the United States, prescribing not only that women are supposed to reproduce, but which women are supposed to reproduce. Those who deviate from this hegemonic idea of a prototypical mother may disproportionately encounter antinatalist norms that prescribe that they should not bear or parent children. In the present article, I advocate for an intersectional psychological study of reproductive norms across the natalism spectrum, grounded in interdisciplinary insights and an understanding of systems of power and oppression. I discuss three common areas of interdisciplinary research related to reproductive norms: (a) pronatalism as a limit to women’s freedom, (b) racism and the control of Black women’s reproduction, and (c) queer perspectives on reproduction. Informed by intersectionality and stigma frameworks, I propose a generative model and six research questions that serve as a research agenda for the psychological study of reproductive norms across the natalism spectrum.

Factors associated with medical help-seeking for infertility in developed countries: A narrative review of recent literature

The reasons why people decide for or against seeking medical help for infertility are still far from clear. With advances in reproductive medicine, use of medically-assisted reproduction has increased over the last three decades. Over the same period, an appreciable amount of quantitative studies on the determinants of medical help-seeking for infertility has accumulated. However, to our knowledge this narrative review is the first to summarize and evaluate findings from these studies. This review includes 39 studies carried out in 11 countries, covering the period 1990-2019. We have identified five categories of determinants of help-seeking: socio-demographic variables, socio-economic factors, reproductive history, attitudes, and psychological factors. Each category consists of several variables. Considerable knowledge has accumulated on socio-economic variables, indicating that there is social inequality in access to treatments in several countries. Less is known about marital status, attitudes and psychological factors. Findings on the latter two mostly derive from two US surveys. Overall, the body of research appears heterogeneous and fragmented. Studies differ in central aspects of study design (definitions of the analysis sample and of help-seeking, type of analysis (bivariate or multivariate), set of variables included in multivariate studies) making comparisons of findings difficult. Low comparability is reinforced by country differences in the provision of treatment, legislation on access and treatment coverage. The majority of papers lack a theoretical foundation or reference to any theory. Using a theoretical framework to guide empirical research could help to overcome the problems described above. Single-country studies should include information on legal and cultural context. More studies from countries other than the US are needed as well as multi-country studies in order to develop a systematic understanding of how macro-level structures relate to decisions about medical help-seeking. This review should assist future researchers in their attempt to conduct studies on help-seeking for infertility.

Variation in Self-Perceived Fecundity among Young Adult U.S. Women

BACKGROUND

Individuals' perceptions of their fecundity, or biological ability to bear children, have important implications for health behaviors, including infertility help-seeking and contraceptive use. Little research has examined these perceptions among U.S. women.

METHODS

This cross-sectional study examines perceptions of one's own fecundity among U.S. women aged 24 to 32 who participated in the 2009-2011 rounds of the National Longitudinal Survey of Youth (1997) cohort. Analyses were limited to 3,088 women who indicated that they or their partners never received a doctor's diagnosis regarding fertility difficulties.

RESULTS

Of the women in the sample, 67% perceived their hypothetical chances of becoming pregnant as very likely; the remainder perceived their chances as somewhat likely (13%), not as likely (15%), or provided a "don't know" response (6%). Twenty-six percent of Black women and 19% of Latina women perceived themselves as not very likely to become pregnant, compared with only 12% among non-Black/non-Latina women (p < .001). Only 6% of women with a college degree perceived their chances of becoming pregnant as not very likely, compared with 36% among women without a high school degree (p < .001). Racial/ethnic and educational differences persisted in fully adjusted models. Other factors associated with fecundity self-perceptions include partnership status, parity, fertility expectations, sexual activity, prolonged exposure to unprotected intercourse for at least 6 and/or 12 months without becoming pregnant, and self-rated health.

CONCLUSIONS

Findings indicate that self-perceived fecundity differs systematically by demographic and other characteristics. This phenomenon should be investigated further to understand how it may influence disparities in health behaviors and outcomes.

Increased risk of severe maternal morbidity among infertile women: analysis of US claims data

BACKGROUND

Severe maternal morbidity continues to be an issue of national and global concern and is increasing in incidence. The incidence of infertility is also on the rise, and infertile women experience a higher risk of incident chronic medical disease and cancer, suggesting that fertility may serve as a window to a woman's overall health.

OBJECTIVE

To investigate the risk of severe maternal morbidity by maternal fertility status.

MATERIALS AND METHODS

This was a retrospective cohort analysis using Optum's de-identifed Clinformatics Data Mart Database between 2003 and 2015. Infertile women stratified by infertility diagnosis, testing, or treatment were compared to fertile women seeking routine gynecologic care. In both groups, only women who underwent pregnancy and delivery of a singleton during the follow-up period were included. Main outcomes were severe maternal morbidity indicators, defined by the Centers for Disease Control and Prevention and identified by International Classification of Diseases 10^th Revision and Common Procedural Technology codes within 6 weeks of each delivery. Results were adjusted for maternal age, race, education, nulliparity, smoking, obesity, delivery mode, preterm birth, number of prenatal visits, and year of delivery.

RESULTS

A total of 19,658 women comprised the infertile group and 525,695 women comprised the fertile group. The overall incidence of any severe maternal morbidity indicator was 7.0% among women receiving fertility treatment, 6.4% among women receiving a fertility diagnosis, 5.5% among women receiving fertility testing, and 4.3% among fertile women. Overall, infertile women had a significantly higher risk of developing any severe maternal morbidity indicator (adjusted odds ratio, 1.22; confidence interval, 1.14-1.31, P < .01) as well as a significantly higher risk of disseminated intravascular coagulation (adjusted odds ratio, 1.48; confidence interval, 1.26-1.73, P < .01), eclampsia (adjusted odds ratio, 1.37; confidence interval, 1.05-1.79, P < .01), heart failure during procedure or surgery (adjusted odds ratio, 1.54; confidence interval, 1.21-1.97, P < .01), internal injuries of the thorax, abdomen, or pelvis (adjusted odds ratio, 1.59; confidence interval, 1.12-2.26, P < .01), intracranial injuries (adjusted odds ratio, 1.77; confidence interval, 1.20-2.61, P < .01), pulmonary edema (adjusted odds ratio, 2.18; confidence interval, 1.54-3.10, P < .01), thrombotic embolism (adjusted odds ratio, 1.58; confidence interval, 1.14-2.17, P < .01), and blood transfusion (adjusted odds ratio, 1.50; confidence interval, 1.30-1.72, P < .01) compared to fertile women. Fertile women did not face a significantly higher risk of any maternal morbidity indicator compared to infertile women. In subgroup analysis by maternal race/ethnicity, the likelihood of severe morbidity was significantly higher among fertile black women compared to fertile white women. There was no difference between infertile black women and infertile white women after multivariable adjustment.

CONCLUSION

Using an insurance claims database, we report that women diagnosed with infertility and women receiving fertility treatment experience a significantly higher risk of multiple indicators of severe maternal morbidity compared to fertile women. The increased risk of severe maternal morbidity noted among fertile black women compared to fertile white women is attenuated among infertile black women, who face risks similar to those of infertile white women.

Does Self-Identifying as Having a Health Problem Precede Medical Contact? The Case of Infertility

Studies of medical help-seeking presume that self-identifying as having a health problem precedes medical contact, but this ordering of the identity-behavior relationship has not been systematically examined. We used longitudinal data from the National Survey of Fertility Barriers (2004 to 2010) on 412 women with infertility to document the temporal relationship between self-identifying as having a fertility problem and making medical contact. The symbolic interactionist perspective suggests that infertility will be perceived as identity disruption and that in response women will align self-identity and medical behavior over time. Cross-tabulation analysis indicated that more women do self-identify as having a fertility problem first (24 percent) as opposed to making medical contact first (5.5 percent). There was also a tendency toward aligning self-identification and behavior over time. Latent class analyses revealed six patterns: 1) consistently involved, 2) early consulters, 3) consistently uninvolved, 4) consistent perceivers, 5) medical dropouts, and 6) early perceivers. Strong fertility intent and primary infertility, two identity-relevant characteristics, had the strongest associations with latent class membership. The relationship between self-identification and medical help-seeking is thus dynamic and complex.

Measuring the Multidimensional Reproductive Concerns of Young Adult Male Cancer Survivors

Purpose: The aims of this study were to adapt the multidimensional Reproductive Concerns After Cancer (RCAC) scale for use with young adult (YA) male cancer survivors, defined as current age 18-35 years and at least 1 year postdiagnosis, and to examine the factor structure, reliability, and validity of the newly adapted RCAC-Male (RCAC-M) scale. Methods: We conducted cognitive interviews with 10 YA male cancer survivors to inform modifications to RCAC item wording. Online surveys were then completed by 170 YA male cancer survivors. We used confirmatory factor analysis to examine structural models of the RCAC-M scale, and assessed reliability and construct validity. Results: The oblique six-factor model of the RCAC-M scale provided the best model fit. Omega total and Revelle's omega total estimates for all six three-item subscales were in the nearly satisfactory to good range (0.69-0.88). As hypothesized, men who wanted to have a baby and men who believed that having a biological child was very important scored higher on at least one RCAC-M subscale. We observed correlations in the expected directions between the RCAC-M and measures of depression and health-related quality of life. Conclusion: The RCAC-M scale is a multidimensional scale that is best represented as a profile of subscale scores. This scale demonstrated good reliability and construct validity and can be used to inform tailored interventions to more effectively address men's reproductive concerns.

Pathways to Parenthood in Social and Family Context: Decade in Review, 2020

OBJECTIVE

This article reviews research from the past decade on patterns, trends, and differentials in the pathway to parenthood.

BACKGROUND

Whether, and under what circumstances, people become parents has implications for individual identity, family relationships, the well-being of adults and children, and population growth and age structure. Understanding the factors that influence pathways to parenthood is central to the study of families and can inform policies aimed at changing childbearing behaviors.

METHOD

This review summarizes recent trends in fertility as well as research on the predictors and correlates of childbearing, with a focus on the United States and on research most relevant to family scholars. We document fertility differentials and prevailing explanations for variation across sub-groups and discuss alternative pathways to parenthood, such as adoption. The article suggests avenues for future research, outlines emerging theoretical developments, and concludes with a discussion of fertility policy.

RESULTS

U.S. fertility has declined in recent years; whether fertility rates will increase is unclear. Elements of the broader social context such as the Great Recession and increasing economic inequality have impacted pathways to parenthood, and there is growing divergence in behaviors across social class. Scholars of childbearing have developed theories to better understand how childbearing is shaped by life course processes and social context.

CONCLUSION

Future research on the pathways to parenthood should continue to study group differentials, refine measurement and theories, and better integrate men and couples. Childbearing research is relevant for social policy, but ideological factors impact the application of research to policy.

Is there evidence of weathering among women seeking fertility treatments?: Evidence and insights

Racial disparities in outcomes of assisted reproductive technologies (ART) are well-documented, and evidence of racial disparities in other forms of fertility treatments has also been observed. To date, much of the research on these disparities has focused on individual-level causes. This paper contextualizes these disparities using the weathering hypothesis. Using the National Survey of Family Growth and exploratory analyses of the National Health and Nutrition Examination Survey, this study evaluates whether there is evidence of weathering among women of color seeking fertility treatments. The study finds inconsistent evidence of weathering among these groups. However, the study is limited by weaknesses in the available data. The paper demonstrates the promise and limits of the available data to answer empirical questions regarding disparities in fertility treatments that have spurred a national public health action plan and numerous commentaries from scholars and professional organizations. The paper concludes with a discussion of other possible causes of these disparities and a description of next steps needed in the field to better understand both the "under the skin" and social processes that underlie disparities in fertility treatment outcomes.

Assisted reproductive technology use in the United States: a population assessment

OBJECTIVE

To study social and demographic differentiation of assisted reproduction technology (ART) use at the population level in the United States.

DESIGN

Population-based study.

SETTING

Not applicable.

PATIENT(S)

Women 15-49 years old in the American Community Survey and National Vital Statistics Birth Certificate data from 2010-2017.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Birth rate after ART by major sociodemographic categories and likelihood of having an ART birth.

RESULT(S)

Net of education, age, period, and marital status, the incidence rates of ART births are lower for black women (0.57 times; 95% CI, 0.52-0.62) and Hispanic women (0.67 times; 95% CI, 0.57-0.62) relative to white women's rates; for Asian women, the incidence rates are 1.21 times that of white women's rates. Further, the incidence rates of ART births are higher for women with more than a 4-year degree (2.08 times; 95% CI, 1.90-2.27) relative to women with a 4-year degree, and are lower for women with less education. Women who are married have an incidence rate of ART that is 5.72 times (95% CI, 5.37-6.09) that of unmarried women. The incidence rates for 2013-2016 are statistically significantly higher than for 2010 by a factor of 1.16 (95% CI, 1.02-1.31), 1.16 (95% CI, 1.03-1.31), 1.27 (95% CI, 1.12-1.43), and 1.51 (95% CI, 1.43-1.82), respectively. The educational differences in ART exist across all age groups from 20 to 49, but are the largest among the 35-39 and 40-44 age groups.

CONCLUSION(S)

Large differences in the risk of an ART birth and the proportion of births and the total fertility rate due to ART exist across period, age, race, education, and marital status groups in the United States. Current measures of ART births may disguise an unmet need for ART.

Estimates of donated sperm use in the United States: National Survey of Family Growth 1995-2017

OBJECTIVE

To provide national estimates of donor insemination (DI) use in the United States and a description of the population of users.

DESIGN

Population estimates were generated from nationally representative data through weighted proportions and count estimates.

SETTING

Not applicable.

PATIENT(S)

Participants were U.S. women of childbearing age (15-44 years) sampled for interview in the National Survey of Family Growth.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Respondents who reported having received artificial insemination were asked the origin of the sperm. Responses could include husband/partner, donor only, or mixed donor and husband/partner.

RESULT(S)

In 1995, an estimated 170,701 (95% confidence interval 106,577-234,825) women had undergone DI using donor or mixed sperm. In 2015-2017, 440,986 (95% confidence interval 108,458-773,513) women were estimated to have used it. The DI users were mostly white, urban, older, college-educated, and had high family incomes.

CONCLUSION(S)

The DI use changed over time, from a decrease between 1995 and 2013 to a precipitous growth in 2015 to 2017. In recent years, nearly half a million women may be dealing with personal, relationship, and familial issues born of DI use. The United States does not maintain records on the usage of donor sperm, but better tracking of the use and outcomes of treatment would provide better estimates of the size of the affected population.

Medical conditions, pregnancy perspectives and contraceptive decision-making among young people: an exploratory, qualitative analysis

OBJECTIVE

To explore perspectives on family planning among young people who perceive they are infertile or will have difficulty carrying a pregnancy to term owing to medical conditions or procedures.

METHODS

This exploratory analysis examined pregnancy plans and contraceptive behavior among 12 young adults with a diagnosed medical condition or who had undergone a medical procedure associated with impaired fertility, and who had discussed fertility with a healthcare provider. We utilized data from a larger study investigating prospective pregnancy intentions and plans among 50 young (ages 18-24) women and their male partners (n=100).

RESULTS

Medical conditions included endometriosis, polycystic ovary syndrome, and lupus. For some, medical conditions/procedures led to use of no or less effective contraception; perceived risk for pregnancy was low, though seven participants had previously experienced pregnancies. Participants also described how medical conditions altered their timelines for pregnancy and overall desire for children; for example, one participant described continuing an unplanned pregnancy because she feared it would be her only chance to parent.

CONCLUSION

This exploratory analysis suggests that among young people, medical issues perceived to affect fertility and pregnancy may influence pregnancy planning and contraceptive behavior. Young people may lack knowledge about fertility and the impact of a medical condition; thus it is critical that providers clarify the difference between anticipated difficulty conceiving and complete infertility. Tailored contraceptive care is needed for young adults with medical conditions that may affect fertility to ensure they have the necessary information to make informed family planning decisions.

IMPLICATIONS

Medical conditions known to affect fertility may influence young people's family planning desires and behaviors. Understanding how young adults process information about medical conditions' impact on their fertility and change or make plans in response is important in order to best meet their family planning needs.

Disparities in accessing infertility care in the United States: results from the National Health and Nutrition Examination Survey, 2013-16

OBJECTIVE

To investigate infertility rates and access to infertility care among women in the United States.

DESIGN

Retrospective cross-sectional.

SETTING

Not applicable.

PATIENT(S)

Women between 20 and 44 years-old who participated in the National Health and Nutrition Examination Survey between 2013 and 2016 and answered questions RHQ074 ("have you ever attempted to become pregnant over a period of at least a year without becoming pregnant?") and RHQ076 ("have you ever been to a doctor or other medical provider because you were unable to become pregnant?").

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Rates of infertility and accessing infertility care.

RESULT(S)

Women reported infertility at a rate of 12.5% (95% confidence interval, 10.8-14.4). Higher infertility rates were noted with increasing age and body mass index. There were no differences in infertility rates by race/ethnicity, education, income, U.S. citizenship, insurance, or primary location of health care. However, women with less than a high school diploma accessed infertility care less than women with a college degree (5.0% vs. 11.6%). Women with incomes less than $25,000 sought infertility care less than those with incomes above $100,000 (5.4% vs. 11.6%). Non-U.S. citizens accessed infertility care less than U.S. citizens (6.9% vs. 9.4%), and uninsured women reported fewer visits for infertility than insured women (5.9% vs. 9.9%). Women who used the emergency department as their primary medical location reported accessing infertility care less than those who relied on a hospital outpatient unit (1.4% vs. 14.9%).

CONCLUSION(S)

These nationally representative findings highlight the need to address disparities in access to infertility care.

The Conscripted Curriculum and the Reproduction of Racial Inequalities in Contemporary U.S. Medical Education

In their attempt to address racial disparities in the provision of healthcare, the U.S. medical profession has reproduced racial inequalities of their own. In this article, I draw upon interview data with medical educators and students to detail how medical educators routinely offload the instruction on the social underpinnings and consequences of race onto students, particularly students of color. I develop the concept of the conscripted curriculum to capture how students' social identities are utilized by educators in the professionalization process. While there are exceptions in curricular approaches, most educators create the conscripted curriculum by eliciting students to share their social experiences with race in the small group setting while only providing students with didactic material on biological understandings of race. As a result, students of color report experiencing more emotionally exhausting and unrewarded labor than their white peers, and educators further devalue the social implications of race for healthcare.

A limited market: the recruitment of gay men as surrogacy clients by the infertility industry in the USA

Gestational surrogacy via egg donation is an expensive - and sometimes ambivalently undertaken - but increasingly popular route to planned fatherhood for some gay men. The surrogacy market in the USA plays an important role for gay men with the financial resources to access these services, as it is currently the only stable, commercial market in which there are legal protections for openly gay men. While a small, ethnographic and qualitative literature on the experiences of gay fathers via surrogacy exists, less is known about the state of the surrogacy industry towards gay men as clients. Here I investigate the surrogacy industry in the USA to ask how welcome gay men are in this market. I do so via a content analysis of patient/client recruitment on infertility clinic and surrogacy agency websites. Content analysis of 547 websites indicates that the majority of infertility clinics (62%) and 42% of surrogacy agencies do not directly advertise or appear to be welcoming to gay men. A minority of gay-friendly clinics and agencies, which cluster geographically, actively recruit gay men, creating a limited but niche market. The unequal recruitment of gay men as infertility clients reflects how normative ideas about gender, sexuality and social class are reproduced in the infertility industry. This, in turn, may impact gay men's procreative consciousness and decision-making about parenting, and exacerbate inequalities around their access to intentional genetic parenthood.

Gatekeepers for infertility treatment? Views of ART providers concerning referrals by non-ART providers

Many patients who might benefit from treatment using assisted reproductive technology (ART) do not receive it, raising critical questions of why, and how best to overcome existing barriers. In-depth interviews of approximately 1 h each were conducted with 27 ART providers (17 physicians and 10 other healthcare providers). These interviewees suggest that non-ART providers may serve as gatekeepers in a complex system, involving not only individual-level, but also dyadic and institutional, processes and factors related to provider-patient relationships. Differences emerge concerning 'who' refers patients for ART (e.g. what types of provider), 'how' (amount, type and specificity of information offered), 'when' (delayed or not) and 'why or why not', and how patients respond to referrals, once made. At least seven types of clinician (general practitioners, obstetricians/gynaecologists, paediatricians, geneticists, psychologists and oncologists) may refer patients. Barriers to referral include indistinct boundaries between specialties and provider discomfort discussing reproduction and sex. These data, the first to explore dynamic factors and processes related to provider-patient relationships and interactions in referrals of patients for ART, suggest several key issues (e.g. non-ART providers' roles as gatekeepers), and implications for future education, practice, guidelines and research, highlighting a research agenda, and the need for targeted education for different groups of clinicians.

Decline in ethical concerns about reproductive technologies among a representative sample of US women

Public awareness and utilization of assisted reproductive technology has been increasing, but little is known about changes in ethical concerns over time. The National Survey of Fertility Barriers, a national, probability-based sample of US women, asked 2031 women the same set of questions about ethical concerns regarding six reproductive technologies on two separate occasions approximately 3 years apart. At Wave 1 (2004-2007), women had more concerns about treatments entailing the involvement of a third party than about treatments that did not. Ethical concerns declined between Wave 1 and Wave 2, but they declined faster for treatments entailing the involvement of a third party. Ethical concerns declined faster for women with greater levels of concern at Wave 1. Initial ethical concerns were higher, and there was less of a decline in ethical concerns for women with higher initial levels of religiosity.

Responding to Infertility: Lessons From a Growing Body of Research and Suggested Guidelines for Practice

Infertility is a common, yet often misunderstood, experience. Infertility is an important topic for family scientists because of its effects on families; its relevance to research in related areas, such as fertility trends and reproductive health; and its implications for practitioners who work with individuals and couples experiencing infertility. In this review, we focus on common misperceptions in knowledge and treatment of infertility and highlight insights from recent research that includes men, couples, and people with infertility who are not in treatment. The meaning of parenthood, childlessness, awareness of a fertility problem, and access to resources are particularly relevant for treatment seeking and psychosocial outcomes. On the basis of insights from family science research, we provide specific guidelines for infertility practice within broader social contexts such as trends in health care, education, employment, and relationships. Guidelines are presented across three areas of application: infertility education for individuals, families, and practitioners; steps to support the emotional well-being of those affected by infertility; and understanding of treatment approaches and their implications for individuals and couples.

Disparities in Counseling Female Cancer Patients for Fertility Preservation

BACKGROUND

Female cancer patients who are exposed to gonadotoxic chemotherapy are at risk of future infertility. Research suggests that disparities in fertility preservation counseling (FPC) may exist. Previous research is limited by recall bias; therefore, this study examined objective electronic medical chart data regarding FPC at an academic medical center.

MATERIALS AND METHODS

This study included reproductive-aged women (18-45 years old) with a diagnosis of breast, gynecological, or hematological cancer and who were exposed to a gonadotoxic chemotherapeutic agent from 2009 to 2013. Chi-square and logistic regression analyses were utilized to analyze disparities in FPC.

RESULTS

Two hundred fifty-nine women met the study criteria. One hundred eighty-one women were diagnosed with breast cancer, 52 with hematological cancer, and 26 with gynecological cancer. 160/259 (62%) women had documented counseling for fertility preservation (FP), 60 (23%) women were not counseled as counseling was determined to be "not applicable," 16 (6%) women were not counseled and no explanation was given for the lack of counseling, and counseling was not documented in 23 (9%) charts. Age, marital status, and racial/ethnic background were related to counseling status. Patients with gynecological or hematological cancer were more likely to be counseled than other patients. Logistic regression results demonstrated that FPC was largely driven by cancer diagnosis.

CONCLUSIONS

Although cancer diagnosis was the greatest predictor of FPC, disparities were evident in the counseling of female cancer patients for FP treatment. Equality in counseling female patients for FP treatment is imperative to reduce the risk of emotional harm and future infertility.

Reproductive policy and the social construction of motherhood

BACKGROUND

Reproductive technologies allow women to embrace or forgo motherhood, but a woman's ability to make autonomous reproductive choices depends on access to these technologies. In the United States, public policies — laws, regulations, appropriations, and rulings — have either broadened or narrowed this access.

QUESTION

Have U.S. public policies affecting reproductive choices conformed to attitudinal distinctions about motherhood itself?

METHODS

I identified policies covering infertility, contraception, and abortion and examined them contextually within the Ingram-Schneider social construction framework.

FINDINGS

Women's choices fell within social construction quadrants as being positively portrayed and powerful; negatively portrayed but powerful; positively portrayed but powerless; and negatively portrayed and powerless. Married heterosexual women embracing motherhood were likely to be viewed positively and to reap benefits. Women forgoing motherhood, poor women, and women seeking to form nontraditional families were likely to be viewed negatively and to bear burdens; critical among these burdens was restriction of access to technologies that could be used to support a decision to avoid motherhood or to achieve motherhood through nontraditional methods.

CONCLUSION

Yes, U.S. public policies affecting reproductive choices have conformed to attitudinal distinctions about motherhood itself. These policies may also have altered those choices.

Clinical vignettes and global health considerations of infertility care in under-resourced patients

The ability to receive standard of care for a diagnosis of infertility is a factor of one’s financial state and educational level, which are often correlated. Providing infertility care in an under-resourced tertiary care environment provides challenges but also opportunities for unique successes in creating a family. Among the under-represented populations are recent immigrants and refugees. Challenges arise when the infertility treatment is futile or when the standard of care is inaccessible due to cost and scheduling. Unique accomplishments are noted when families are built and hope is restored for couples fleeing from genocide and war-inflicted countries. This article will highlight two clinical vignettes from the Division of Reproductive Endocrinology and Infertility clinic at Boston University School of Medicine/Boston Medical Center. Thereafter, the article will summarize the barriers to care in the United States among those with low socioeconomic status, with non-dominant racial status (non-Caucasian), and with refugee status. All identifiers have been removed and names altered in the patient vignettes.

Cross-cultural comparison of fertility specific quality of life in German, Hungarian and Jordanian couples attending a fertility center

BACKGROUND

Only a few studies have reported cross-cultural comparisons regarding psychosocial consequences of infertility. Differences between societies with different cultural backgrounds were revealed and seemed to be based on the importance of pronatalism. Our aim was to measure cross-cultural differences in fertility specific quality of life of infertile couples in Germany, Hungary and Jordan who attend a fertility center in a cross-sectional study.

METHODS

A cross-sectional study was conducted in one fertility clinic in Germany, in five fertility clinics in Hungary and in one fertility clinic in Jordan. Overall 750 couples (252 couples in Jordan, 246 couples in Germany and 252 couples in Hungary) attending the first medical infertility consultation were asked to fill out our questionnaire set. Fertility specific quality of life (FertiQoL) and sociodemographic differences were measured between couples from three countries.

RESULTS

Jordanian couples had the shortest relationship (5.8 ± 4.3 yrs.), though they reported the longest duration of child wish (4.2 ± 3.6 yrs.) and fertility treatments (3.0 ± 3.3 yrs.). The proportion of high education was considerably higher in Jordanian women and men (60 % and 66 %, respectively) compared to the other two samples. First, marked cross-country differences were obtained on Emotional, Mind/Body and Relational subscales of the FertiQoL, indicating that Jordanian couples reported poorer fertility-related quality of life than Germans and Hungarians (p < 0.001). After controlling for the sociodemographic and medical variables, a significant difference only in the Emotional domain was observed (p < 0.001).

CONCLUSIONS

The study revealed only a few cultural based differences in fertility specific quality of life between the couples of the three countries. Thus, infertility counselors should pay attention to psychosocial problems rooted in individual sociocultural aspects of the infertile couple regardless of cultural stereotypes. Further studies should identify sociocultural factors within different subgroups of infertile patients instead of focusing different societies as a whole because intra-cultural psychosocial differences in experiencing infertility seem to be more important for the individual patient than intercultural differences.

Cross-cultural comparison of fertility specific quality of life in German, Hungarian and Jordanian couples attending a fertility center

Background

Only a few studies have reported cross-cultural comparisons regarding psychosocial consequences of infertility. Differences between societies with different cultural backgrounds were revealed and seemed to be based on the importance of pronatalism. Our aim was to measure cross-cultural differences in fertility specific quality of life of infertile couples in Germany, Hungary and Jordan who attend a fertility center in a cross-sectional study.

Methods

A cross-sectional study was conducted in one fertility clinic in Germany, in five fertility clinics in Hungary and in one fertility clinic in Jordan. Overall 750 couples (252 couples in Jordan, 246 couples in Germany and 252 couples in Hungary) attending the first medical infertility consultation were asked to fill out our questionnaire set. Fertility specific quality of life (FertiQoL) and sociodemographic differences were measured between couples from three countries.

Results

Jordanian couples had the shortest relationship (5.8 ± 4.3 yrs.), though they reported the longest duration of child wish (4.2 ± 3.6 yrs.) and fertility treatments (3.0 ± 3.3 yrs.). The proportion of high education was considerably higher in Jordanian women and men (60 % and 66 %, respectively) compared to the other two samples. First, marked cross-country differences were obtained on Emotional, Mind/Body and Relational subscales of the FertiQoL, indicating that Jordanian couples reported poorer fertility-related quality of life than Germans and Hungarians (p < 0.001). After controlling for the sociodemographic and medical variables, a significant difference only in the Emotional domain was observed (p < 0.001).

Conclusions

The study revealed only a few cultural based differences in fertility specific quality of life between the couples of the three countries. Thus, infertility counselors should pay attention to psychosocial problems rooted in individual sociocultural aspects of the infertile couple regardless of cultural stereotypes. Further studies should identify sociocultural factors within different subgroups of infertile patients instead of focusing different societies as a whole because intra-cultural psychosocial differences in experiencing infertility seem to be more important for the individual patient than intercultural differences.

Does fertility-specific distress vary by race/ethnicity among a probability sample of women in the United States?

This study explored whether fertility-specific distress varied by race/ethnicity among a nationally representative sample of US women. Participants were 2363 White (n = 1266), Black (n = 569), Hispanic (n = 453), and Asian (n = 51) women who participated in the National Survey of Fertility Barriers. Participants were given the Fertility-Specific Distress Scale and assessed for strength of pregnancy intent, primary versus secondary infertility, and socioeconomic hardship. Black women reported lower levels of fertility-specific distress than White women, but these were fully mediated by the strength of pregnancy intentions. Primary versus secondary infertility and economic hardship were not associated with fertility-specific distress.

Supply of and demand for assisted reproductive technologies in the United States: clinic- and population-based data, 1995-2010

OBJECTIVE

To study national-level trends in assisted reproduction technology (ART) treatments and outcomes as well as the characteristics of women who have sought this form of infertility treatment.

DESIGN

Population-based study.

SETTING

Not applicable.

PATIENT(S)

For CDC: All reporting clinics from 1996-2010. For NSFG: for the logistic analysis, sample comprising 2,325 women aged 22-44 years who have ever used medical help to get pregnant, excluding women who used only miscarriage prevention services.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

CDC data (number of cycles, live birth deliveries, live births, patient diagnoses); and NSFG data (individual use of ART procedures).

RESULT(S)

Between 1995 and 2010, use of ART increased. Parity and age are strong predictors of using ART procedures. The other correlates are higher education, having had tubal surgery, and having a current fertility problem.

CONCLUSION(S)

The two complementary data sets highlight the trends of ART use. An increase in the use of ART services over this time period is seen in both data sources. Nulliparous women aged 35-39 years are the most likely to have ever used ART services.

A New Way to Estimate the Potential Unmet Need for Infertility Services Among Women in the United States

BACKGROUND

Fewer than 50% of women who meet the medical/behavioral criteria for infertility receive medical services. Estimating the number of women who both meet the medical/behavioral criteria for infertility and who have pro-conception attitudes will allow for better estimates of the potential need and unmet need for infertility services in the United States.

METHODS

The National Survey of Fertility Barriers was administered by telephone to a probability sample of 4,712 women in the United States. The sample for this analysis was 292 women who reported an experience of infertility within 3 years of the time of the interview. Infertile women were asked if they were trying to conceive at the time of their infertility experience and if they wanted to have a child to determine who could be considered in need of services.

RESULTS

Among U.S. women who have met medical criteria for infertility within the past three years, 15.9% report that they were neither trying to have a child nor wanted to have a child and can be classified as not in need of treatment. Of the 84.9% of infertile women in need of treatment, 58.1% did not even talk to a doctor about ways to become pregnant.

DISCUSSION

Even after taking into account that not all infertile women are in need of treatment, there is still a large unmet need for infertility treatment in the United States.

CONCLUSION

Studies of the incidence of infertility should include measures of both trying to have a child and wanting to have a child.

Who receives a medical evaluation for infertility in the United States?

OBJECTIVE

To investigate characteristics of receiving a medical evaluation for infertility among infertile women.

DESIGN

Prospective cohort.

SETTING

Academic institution.

PATIENT(S)

A total of 7,422 women who reported incident infertility between 1989 and 2009 in the Nurses' Health Study II.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Report of receiving a medical evaluation for infertility.

RESULT(S)

Approximately 65% of women who reported infertility had a medical evaluation for infertility. Infertile women who were parous (relative risk [RR] = 0.81, 95% confidence interval [CI] 0.78-0.84), older, current smokers (RR = 0.89, 95% CI 0.83-0.96), or who had a higher body mass index (BMI) were less likely to report receiving a medical infertility evaluation. Infertile women who exercised frequently, took multivitamins (RR = 1.03, 95% CI 1.00-1.07), lived in states with comprehensive insurance coverage (RR = 1.09, 95% CI 1.00-1.19), had a high household income, or who had a recent physical examination (RR = 1.15, 95% CI 1.06-1.24) were more likely to report receiving a medical infertility evaluation.

CONCLUSION(S)

These findings highlight demographic, lifestyle, and access barriers to receiving medical infertility care. Historically, the discussion of barriers to infertility care has centered on financial access, geographic access, and socioeconomic status. Our findings build off literature by supporting previously reported associations and showcasing the importance of demographic and lifestyle factors in accessing care.

Ovarian tissue cryopreservation and retransplantation--what do patients think about it?

Cryopreservation of ovarian tissue has been successfully applied clinically, with over 60 live births to date. The aim of the present study was to perform a survey of patients who have had ovarian tissue cryopreserved in the Department of Obstetrics and Gynecology, Erlangen University Hospital, in order to obtain information about: why patients opt for fertility preservation; their current fertility; pregnancy attempts and outcomes; and their intended plans for the cryopreserved ovarian tissue. In total, 147 women took part in the survey (average age 25.0 ± 7.0 years; response rate 48%; mean follow-up period 6 years). Sixty-six reported regular menstrual cycles; 48 were amenorrhoeic. Sixty-two women had tried to conceive; 33 reported pregnancies. Twenty-five had delivered healthy children after conceiving naturally; eight had conceived with assisted reproduction. Five patients had had their ovarian tissue retransplanted. Although many patients continued to have ovarian function, none of them regretted choosing cryopreservation of ovarian tissue. Cryopreservation of ovarian tissue is an effective option and is very important for women diagnosed with cancer. Analyses of the clinical outcomes in these patients are essential in order to identify those patients capable of benefiting most from the procedure and in order to improve the technique.