Pathways into childbearing delay of men and women in Australia

Australian women's views concerning non-medical egg freezing and factors motivating freezing decisions

OBJECTIVE

We aimed to determine women's views about egg freezing for non-medical reasons and the factors motivating freezing decisions.

DESIGN

In this study, 514 women aged 18-44 years completed an online cross-sectional survey exploring fertility knowledge, reproductive intentions and views concerning non-medical egg freezing.

METHODS

Data were analysed descriptively. Additionally, 14 variables noted as potential motivators in prior literature were entered into a multinomial regression to explore factors that would motivate women to consider freezing their eggs for non-medical reasons.

RESULTS

Views concerning non-medical egg freezing were generally positive, with 61.3% of participants reporting that they would consider egg freezing ('Yes' or 'Maybe'). Factors motivating decisions to freeze varied among women who responded 'Yes', 'Maybe' and 'I don't know' to whether they would consider freezing. The availability of Medicare subsidization and the procedure not affecting future fertility were significant predictors for all three groups of women.

CONCLUSIONS

Acceptability of egg freezing for non-medical reasons was moderate to high. However, there is a need for targeted fertility information to educate women about fertility and optimal times to conceive and freeze their eggs. Future research about views concerning non-medical egg freezing among diverse populations and examining the health economics of this procedure would be beneficial.

The psychosocial outcomes of older parenthood in early to mid-childhood: a mini-review

Recent decades have seen a global trend towards delaying parenthood, referred to as the 'postponement transition'. Whilst there is plentiful research regarding obstetric and paediatric outcomes related to delayed parenthood, relatively little is known about the psychosocial outcomes associated with advanced parental age during early and middle childhood. This mini-review examines the current literature regarding the psychosocial functioning of families headed by older parents. First, we give an overview of the literature that examines the psychological wellbeing of older first-time parents. We then review the literature regarding the quality of the parent-child relationship in older parent families. Finally, we discuss the psychosocial adjustment and cognitive development of children of older parents. We conclude with suggestions for future research avenues.

Childbirth timing and completed family size by the mode of conception-the role of medically assisted reproduction: a population-based cohort study in Australia

Background

With declining total fertility rates to below replacement levels amongst all high-, middle- and low-income countries, coupled with increasing use of medically assisted reproduction (MAR) treatments globally, we describe the impact of these treatments on completed family size and childbearing timing in a country with unlimited publicly funded access to MAR.

Methods

We utilised a unique longitudinal propensity score-weighted population-based birth cohort that included nulliparous mothers who gave birth after all major forms of MAR treatments (assisted reproductive technologies [ART], ovulation induction [OI], and intrauterine insemination [IUI]) and after natural conception (reference category) in Australia, 2003-2017. We followed first-time mothers over their reproductive lifespan (15-50 years). The primary outcome was completed family size (i.e., the mean cumulative number of children per mother of our cohort) and the fertility gap (i.e., adjusted difference in completed family size between MAR conceptions and the reference).

Findings

Our cohort includes 481,866 first-time mothers, mean follow-up of 13.8 years. ART mothers (n = 25,296) were six years older (mean age: 34.6 years) than mothers who conceived naturally (28.7 years (reference)) while OI/IUI mothers were only 2.2 years older (31.0 years) than the reference. ART mothers had up to 27% smaller completed family size (2.54 children) compared to OI/IUI mothers (2.98 children) and natural conception mothers (3.23 children). ART mothers who resided in the lower socioeconomic areas were less likely to reach a similar family size to the natural conception mothers (fertility gap of 0.83 fewer children per ART mother compared to natural conception mothers) than ART mothers who resided in the higher socioeconomic areas (0.43 fewer children).

Interpretation

Greater awareness of the limitations of MAR treatment to resolve childlessness and achieve desired family size is needed. Furthermore, with policymakers increasingly turning to MAR treatment as a tool to reverse declining fertility rates, their potential impact should not be overestimated.

Funding

Australian National Health and Medical Research Council.

Residential proximity to a fertility clinic is independently associated with likelihood of women having ART and IUI treatment

STUDY QUESTION

Is geographic proximity to a fertility clinic associated with the likelihood of women of reproductive age undertaking different forms of medically assisted fertility treatment?

SUMMARY ANSWER

After adjusting for socioeconomic status (SES) and other confounders including a proxy for the need for infertility treatment, women who lived within 15 km of a fertility clinic were 21% more likely to undergo ART treatment and 68% more likely to undergo IUI treatment than those who lived further than 60 km away.

WHAT IS KNOWN ALREADY

In most countries, patients living outside of metropolitan areas are more likely to be more socio-economically disadvantaged and to have less equitable access to healthcare. However, how a woman's residential proximity to fertility clinics predicts utilization of high-cost/high-technology treatment (ART) and low-cost/low-technology treatment (IUI) is limited, and whether socio-economic disadvantage explains much of the hypothesized lower utilization is unknown. Australia's universal insurance scheme provides supportive reimbursement for almost all ART and IUI treatment regardless of age or number of cycles, providing a unique setting to investigate disparities in access to infertility treatment.

STUDY DESIGN, SIZE, DURATION

National population-based observation study of ART and IUI treatment utilization by women across socio-economic gradients and Australian residential locations between August 2015 and December 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Universal insurance claims information on female patients who underwent ART or IUI were provided by Services Australia, comprising 67 670 female patients who accessed 162 795 ART treatments, and 10 211 female patients who accessed 19 615 IUI treatments over a 29-month period. Incidence rates by SES and proximity to fertility clinics were calculated to describe the number of women undergoing at least one ART or IUI treatment cycle per 1000 women of reproductive age (25-44). Treatment frequencies were calculated to describe the average number of ART or IUI treatment cycles per woman of reproductive age who had undergone at least one ART or IUI treatment during the study period. Poisson regression analyses were used to estimate the independent effect on accessibility to infertility treatment by geographic proximity (based on small area locations) to the closest fertility clinic after adjusting for SES, childbearing delay, remoteness area, and marital status.

MAIN RESULTS AND THE ROLE OF CHANCE

On average, 19.1 women per 1000 women of reproductive age underwent at least one fresh or frozen ART cycle, with an average 2.3 ART cycles each, while 3.0 women per 1000 women of reproductive age received at least one IUI cycle, with an average of 1.6 IUI cycles each. After adjusting for SES and other confounders including a proxy for the need for infertility treatment, women who lived within 15 km of a fertility clinic were 21% more likely to undergo ART treatment and 68% more likely to undergo IUI than those who lived over 60 km away. Regardless of geographic location, there was a steady and independent gradient in access to ART treatment based on increasing SES, with women residing in the most advantaged residential quartile having a 37% higher rate of receiving ART treatment compared to those in the most disadvantaged quartile. The negative effect of social disadvantage on ART use became more pronounced as distance from a fertility clinic grew, indicating that the barriers to access to ART care caused by distance were further compounded by the level of socioeconomic advantage of the women's residential location. In contrast, socioeconomic status did not modify the likelihood of using IUI over and above the distance from a fertility clinic. In relation to IUI treatment, differences in utilization by SES disappeared after adjusting for geographic proximity to a fertility clinic, childbearing delay, remoteness area, and marital status.

LIMITATIONS, REASONS FOR CAUTION

Information is aggregated by small geographic areas and it therefore may not reflect individual characteristics. Australia provides partial but comparably supportive reimbursement for both ART and IUI through its universal healthcare system and thus the results may not be fully generalizable to other settings.

WIDER IMPLICATIONS OF THE FINDINGS

Residential proximity to a fertility clinic is a persistent barrier to accessing ART and IUI treatment, regardless of SES, even in countries characterized by supportive public funding, such as Australia. SES is less of a barrier to accessing IUI than ART, presumably driven by the lower cost and fewer clinic visits required with IUI treatment. Safe and effective fertility treatment should be available to all women regardless of where they live.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the Australian National University Research scholarship and by the Higher Degree Research Fee Merit Scholarship. The authors have no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.