Demographic analysis of a low resource, socioculturally diverse urban community presenting for infertility care in a United States public hospital

Racial disparities in the outcomes of euploid single frozen-thawed embryo transfer cycles - analysis of the Clinical Outcome Reporting System of the Society for Assisted Reproductive Technology 2016-2018 data

OBJECTIVE

To evaluate if in pregnancies conceived with the transfer of single genetically tested embryos, maternal race and ethnicity relate to pregnancy outcome.

DESIGN

Retrospective cohort.

SETTING

Data available in the Clinical Outcome Reporting System of the Society for Assisted Reproductive Technology (SART-CORS) for years 2016-2018.

PATIENT(S)

Autologous frozen-thaw embryo transfer (FET) cycles with transfer of single genetically tested embryo in SART-CORS for years 2016-2018; cycles associated with diagnoses of recurrent pregnancy loss, gestational carrier, donor egg and donor embryo were excluded.

INTERVENTION(S)

Information on race and ethnicity linked with in vitro fertilization and FET cycles available in SART-CORS.

MAIN OUTCOME MEASURE(S)

Multivariable analyses using generalized estimating equation examined the relationship between categories of race and ethnicity with the following outcomes: Pregnancy positive β hCG (human chorionic gonadotropin), clinical pregnancy, pregnancy loss (early [at gestation <13 weeks] and late [loss between ≥13 and <20 weeks]), preterm (<37 weeks), term (≥37 weeks) and live birth. Covariates adjusted for included age, body mass index, anti-Mullerian hormone, infertility diagnosis and smoking history.

RESULT(S)

Seventy-nine thousand four hundred and sixteen FET cycles met the eligibility criteria. Information on race and ethnicity was specified for 50,820 (64.0%) and was not known in 28,723 (36%) of the cycles. The population was predominantly non-Hispanic White (44%); non-Hispanic Black comprised 2.7%, Asian 12.3%, Hispanic 3.4%, and American Indian, Pacific Islander, Hawaiian, and Alaskan comprised 0.2% of the population. Nearly 1.0 % self-identified with more than one race. On multivariable analyses, pregnancies in non-Hispanic Black and in Hispanic women (compared with non-Hispanic Whites') were significantly more likely to result in in preterm birth. Compared with non-Hispanic White women, the likelihood of live birth was significantly lower in non-Hispanic Blacks, Asian, Hispanic, American Indian, Pacific Islander, Hawaiian, and Alaskan women. The likelihood for delivery by Cesarean was also disproportionately higher in the non Hispanic Black and, Hispanic women and in those identifying with more than one race (0.023) compared with non-Hispanic White women.

CONCLUSION(S)

Racial and ethnic differentials are apparent in the outcomes of FET conceived pregnancies resulting from the transfer of single genetically tested embryos.

Neighborhood deprivation and racial differences in in vitro fertilization outcomes

BACKGROUND

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Characteristics of patients seeking fertility care in a low-income setting

OBJECTIVE

Patients face challenges accessing fertility treatment due to barriers such as financial burdens, delayed referral to Reproductive Endocrinologists (REI), low medical literacy, language barriers and numerous other health disparities. Medicaid in New York offers coverage for office visits, blood tests, hysterosalpingograms (HSGs), and pelvic ultrasounds for infertility. The aim of this study is to delineate the characteristics of this underserved population and determine their ability to complete the initial fertility workup.

METHODS

This was a retrospective study of all patients seeking fertility care at a single resident/fellow REI clinic in New York from September 2020 - January 2022.

RESULTS

During the study period, 87 patients (avg age = 35.2y) sought care at the resident/fellow clinic over 126 appointments. The majority of patients had Medicaid insurance and most primary languages spoken included English (70.1%), Spanish (21.8%), and Bengali (3.4%). Documented Race was comprised of mostly Other (46%), African American (21.8%), Asian (17.2%), and White (11.5%). The majority of patients completed a lab workup (70-80%). Fewer patients underwent a scheduled HSG (59.8%) and patients' partners completed a semen analysis (SA) (27.6%). Overall, there was a significant difference in the ability to complete the initial infertility workup (lab tests vs. HSG vs. SA) across all groups regardless of age, insurance type, primary language spoken, race and ethnicity (p<0.05).

CONCLUSIONS

Completing the fertility workup, particularly the male partner workup and imaging studies, can present challenges for underserved patients with infertility. Understanding which patient characteristics and societal factors restrict access to fertility care requires further investigation to improve access to fertility care in underserved communities.

Reproductive inequity and inferior intrauterine insemination outcomes in patients with limited English proficiency: a retrospective cohort study

OBJECTIVE

To evaluate if language preference influences intrauterine insemination outcomes.

DESIGN

Retrospective cohort.

SETTING

The study was conducted at an urban medical center in New York from January 2016 to August 2021.

PATIENT(S)

All women older than 18 years undergoing their first IUI cycle with an infertility diagnosis were included.

INTERVENTION(S)

Intrauterine insemination after ovarian stimulation.

MAIN OUTCOME MEASURE(S)

Primary outcomes were intrauterine insemination success rate and duration of infertility before seeking infertility care. The primary outcomes used the Kaplan-Meier estimator to investigate the difference in duration of infertility before specialty consultation and logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI) of clinical pregnancy among English speakers vs. those with limited English proficiency (LEP) undergoing initial IUI. Secondary outcomes included final IUI outcomes compared by language preference. Adjusted analyses controlled for race/ethnicity.

RESULTS

A total of 406 patients were included in this study, of which 86% preferred English, 7.6% preferred Spanish, and 5.2% preferred other. Patients with LEP have longer duration of infertility before seeking infertility care than English-proficient women (mean 4.53 ± 3.65 years vs. 2.01 ± 1.58 years). Although clinical pregnancy rate of initial IUI did not significantly vary (OR, 2.92; 95% CI, 0.68-12.47 unadjusted and OR, 2.88; 95% CI, 0.67-12.35 adjusted), the cumulative pregnancy rate was significantly higher in English-proficient patients than in LEP patients at the time of final IUI (22.32% vs. 15.38%). This is despite a similar number of total IUIs (2.40 English vs. 2.70 LEP). Additionally, LEP patients were significantly more likely to discontinue care after unsuccessful IUI, instead of proceeding to further fertility treatments such as in vitro fertilization.

CONCLUSIONS

Limited English proficiency is associated with longer duration of infertility before initiating care as well as poorer IUI outcomes, including lower cumulative pregnancy rate. Further research is needed to assess what clinical and socioeconomic factors are contributing to lower IUI success rates and lower continuation in infertility care in LEP patients.

Public opinions regarding infertility treatment insurance coverage among marginalized patient populations

PURPOSE

To assess public support for insurance coverage of infertility treatment among marginalized patient groups.

METHODS

A cross-sectional, web survey-based study using a national sample of 1226 US adults. Participants responded to questions measuring their beliefs and attitudes towards support for infertility treatment insurance coverage among specific patient populations. We then evaluated the opinions of only the participants who supported infertility treatment insurance coverage for patients meeting the standard definition of infertility. Associations between demographic data of participants and support for infertility treatment insurance coverage among these marginalized groups were queried.

RESULTS

Of the total responses, 61.9% of the respondents generally supported insurance coverage for infertility. Of the total responses, 54.5% did not support any insurance coverage for lesbian, gay, or transgender patients. Of those who generally supported the insurance coverage for infertility, 53.0% supported coverage for gay patients requiring infertility services, 54.6% supported coverage for lesbian patients, and 42.5% supported coverage for transgender patients. Of the total responses, 47.6% did not support insurance for green card holders, undocumented immigrants, or refugees. Of those who supported the insurance coverage for infertility in general, 63.6% supported insurance coverage for patients with green cards, 29.8% for refugees, and 20.7% for undocumented patients. For disability and genetic conditions, 39.5% did not support coverage for any groups. Of those who support the insurance coverage for infertility in general, there was most support for patients with physical disabilities (60.2%) followed by genetic disease (47.9%), then mental disabilities (31.4%).

CONCLUSION

Even among those who support insurance coverage for infertility in general, approximately less than half of them supported these same treatments for marginalized groups, including the diverse sexuality and gender (DSG), immigrant, and disabled populations. Increased education and awareness of infertility is needed among the general population to garner acceptance of infertility as a disease and support insurance coverage of infertility treatment for all persons.

Access to Fertility Care in Geographically Underserved Populations, a Second Look

Infertility has a prevalence of up to 16% worldwide and is on the rise in developed nations, largely due to pursuing childbearing at advanced reproductive ages. Advances in assisted reproductive technology have benefitted socioeconomically advantaged patients disproportionately. High costs of fertility care are largely responsible for this disparity; however, patients in rural areas also face barriers in accessing both gynecology and reproductive endocrinology subspecialty care. Here, focusing on the USA, we discuss fertility care in geographically underserved areas and low-resource settings, and the impact on reproductive outcomes. Increased innovation to improve patient access to fertility care such as assisted reproductive technology is critical for ensuring equity. Remote monitoring is frequently performed by fertility centers, but partnership with local gynecologists has also been demonstrated to be an effective assisted reproductive technology monitoring method. Telehealth is now in mainstream use and the continued application to reduce geographic barriers to infertility patients is imperative. Partnership between local gynecologists and reproductive endocrinology and infertility specialists may improve patient access to fertility care and provide the unique benefits of continuity and ongoing local social support.

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

Objective

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

Design

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

Setting

Academic medical institutions.

Patient(s)

None.

Intervention(s)

None.

Main Outcome Measure(s)

Health disparities and barriers in access to care.

Result(s)

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

Conclusion(s)

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

Disparities in fertility knowledge among women from low and high resource settings presenting for fertility care in two United States metropolitan centers

Background

Few studies have examined health literacy and fertility knowledge among women from low income, socio-culturally diverse communities presenting for fertility care in the United States. Our study sought to examine demographic predictors of fertility-related knowledge among infertile women from low and high-resource communities in two major metropolitan centers in the United States.

Methods

Fertility Knowledge Assessments were administered to women presenting for fertility care at county medical centers serving low-resource, largely immigrant patients and to women from largely affluent populations presenting to comprehensive fertility centers in two cities. The influence of demographic predictors on fertility knowledge was examined through regression analysis.

Results

A total of 143 women were included in our analysis. In the county hospital/low resource clinic (LR, n = 70), the mean age was 32.8 ± 6.1 years vs 35.0 ± 5.0 years in the fee-for-service/high resource clinic (HR, n = 73). Among the LR patients, 74% were immigrants, 71% had an annual income <$25,000 and 52% had completed high school. Among HR patients, 36% were immigrants, 60% had an annual income >$100,000, and 95% had some college or above. On average, women from HR settings scored 3.0 points higher on the Fertility Knowledge Assessment than their LR counterparts (p < 0.001). Upon multivariate analysis, education level remained the sole independent factor associated with fertility knowledge assessment score (p < 0.001). Stratifying by resource level revealed that income was highly associated with fertility knowledge (p < 0.01) among high resource individuals even when adjusting for education level.

Conclusions

Women from low resource, largely immigrant communities, seeking fertility care have greater disparities in fertility knowledge and lower health literacy compared to women from high resource clinical settings. Further studies are needed to understand these barriers and to develop targeted inventions to lower disparities and improve care for these vulnerable populations.

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 Influence of Diet on Fertility and the Implications for Public Health Nutrition in the United States

Despite growing evidence of the impact of diet on human fertility, few studies have examined the public health implications of this association in the United States (U.S.). This narrative review summarizes current scientific evidence on associations between dietary intake and fertility, discusses challenges in the public health landscape surrounding infertility, and proposes evidence-based recommendations to address these issues. Diets high in unsaturated fats, whole grains, vegetables, and fish have been associated with improved fertility in both women and men. While current evidence on the role of dairy, alcohol, and caffeine is inconsistent, saturated fats, and sugar have been associated with poorer fertility outcomes in women and men. Furthermore, women and men with obesity [body mass index (BMI) ≥ 30 kg/m²] have a higher risk of infertility. This risk is extended to women who are underweight (BMI <20 kg/m²). Diet and BMI influence outcomes during clinical treatment for infertility. Further, women in the U.S. who belong to an underrepresented minority group, have low income, or have low educational attainment, have significantly higher rates of infertility outcomes as compared to women who are non-Hispanic white, have high income, or have high educational attainment. Given this, it may be prudent to integrate nutrition counseling into both clinical guidelines for infertility as well as national dietary guidelines for individuals of reproductive age. Further studies on diet and reproductive health may enhance our ability to improve existing fertility programs across the U.S. and to deliver tailored care to women and men within at-risk groups.