Fertility and sterility, 2015
Ethics Committee of the American Society for Reproductive Medicine
Committee members: Judith Daar, Paula Amato, Jean Benward, Lee Rubin Collins, Joseph B Davis, Leslie Francis, Elena Gates, Sigal Klipstein, Barbara Koenig, Laurence McCullough, Richard Reindollar, Mark Sauer, Rebecca Sokol, Andrea Stein, Sean Tipton, …
In the United States, economic, racial, ethnic, geographic, and other disparities exist in access to fertility treatment and in treatment outcomes. This opinion examines the factors that contribute to these disparities and proposes actions to address them.
Van Der Poel S et al., 2018 · Fertility and Sterility
There are reports that define the significant unmet need for access to fertility care and infertility interventions for heterosexual couples - those who experience involuntary childlessness and who desire a biological child. This need for access to care rarely measures those couples in non-heterosexual relationships, single individuals or in key/neglected populations. This disparity in recognition of need, and resultant lack of access to care is glaring. Universal access and attainment of the highest standard of care requires the provision of high-quality information and services that fulfills, protects and respects all individuals. The objective of this study was to identify the key principles that support access to fertility care and infertility interventions, and to provide a human rights framework to guide processes during the development of draft recommendations to the World Health Organization (WHO) for clinical practice. To evaluate the public health and human rights and gender impact on infertility, a literature review and systematic analysis were conducted to look at the following questions. What are the existing policies, public health directives and research evidence gaps impacting gender and human rights in the context of involuntary childlessness and infertility; and, What human rights principles guide the development and implementation of fertility care and infertility related laws, policies and systems? A detailed search strategy in collaboration with the WHO-HQ librarian, introducing various combinations of a predetermined set of terms was undertaken to identify primary literature, systematic reviews and gray literature, including documentation regarding current status of human rights and gender equality within policy and practices. Using the search strategy defined, we were able to identify 488 articles and documents, of which 102 were found appropriate. They were then categorized using 9 principles previously identified by WHO and used to address the topic of contraception. From this process, we generated a list of 12 principles which will be presented that cover issues such as non-discrimination, non-stigmatization as well as informed-decision making and autonomy, sharing of benefits and ensuring provision of care that includes the recognition of the health and well-being of the parent or parents as well as the children born. During the systematic review of the published data and evidence for the development of draft clinical recommendations to be presented to and for the World Health Organization consideration, it was clear that a human rights framework was required. Our systematic review process used research and policy evidence to support the development of a framework of principles that can better ensure different human rights dimensions are clearly and systematically integrated into the provision of fertility care information and fertility interventions and services.
Practice Committee of the American Society for Reproductive Medicine, 2025 · Fertility and sterility
It has been estimated that only a quarter of persons with infertility in the United States can sufficiently access infertility care. Against this backdrop of disparity, specific populations, including persons of color, sexual and gender minorities, immigrants, and lower-income persons, face barriers that further constrain access to care. This document outlines these communities' barriers and reviews best practice recommendations to extend inclusive access to care for marginalized populations. This reference is intended to support health professionals with knowledge of barriers that limit access to care and to provide practical strategies to improve access and optimize healthcare delivery.
Feinberg EC et al., 2006 · Fertility and sterility
Racial disparity in assisted reproductive technology (ART) outcomes has been reported but remains controversial. Reasons for the disparity are unclear, and access to care has been suggested as a causative factor. In this study, we sought to examine minority utilization of ART in the Department of Defense (DoD) compared with minority utilization in the U.S. ART population. Outcomes from ART were compared between Caucasian (Cau) and African American (AA) patients, and etiologies of disparity were examined. Retrospective cohort study. University-based ART program. PATIENT(S): A total of 1,457 patients undergoing first-cycle fresh, nondonor ART. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Clinical pregnancy rate, live birth rate, implantation rate, spontaneous abortion rate. RESULT(S): Within the DoD population, AA women had a fourfold increase in utilization of ART services relative to the U.S. ART population. In this equal-access-to-care setting, AA women experienced a clinically significant decrease in live birth rate that did not reach statistical significance (29.6% vs. 35.8%, risk ratio [RR] 0.83, 95% confidence interval [CI] 0.67-1.02) and a statistically significant increase in spontaneous abortions compared with Cau women (25% vs. 15.9%, RR 1.57, 95% CI 1.05-2.36). This might be explained, in part, by a higher prevalence of uterine leiomyomas in AA women (30.8% AA vs. 10.7% Cau, RR 2.85, 95% CI 2.06-3.95). For both AA and Cau women, the presence of fibroids at baseline ultrasound was associated with reductions in clinical pregnancy rates (35% with leiomyomas vs. 43.2% without leiomyomas, RR 0.74, 95% CI 0.51-0.98), live birth rates (26.2% vs. 36.0%, RR 0.63, 95% CI 0.44-0.90), and implantation rates (25.6% vs. 31.1% RR 0.82, 95% CI 0.69-0.98). CONCLUSION(S): Utilization of ART services among AA women increased when access to care was improved. A clinically significant reduction in live birth rate and statistically significant increase in spontaneous abortion rate was observed in AA women compared with Cau women. Leiomyomas were three times more prevalent in AA women and reduced ART success, regardless of race. The persistence of racial differences in an equal-access-to-care environment might be explained, in part, by the increased prevalence of leiomyomas in AA women.
Davis JB et al., 2011 · Fertility and Sterility
To determine if disparities in cost and access to commonly prescribed infertility medications exist in predominately minority neighborhoods. A prospective phone survey of pharmacies in Bronx and Westchester counties of New York State was done to assess the availability and cost of commonly used infertility medications. Demographic data for each county was defined by U.S. Census Data. Pharmacies were categorized by ZIP code and the availability and cost for medication determined and compared to the racial composition of that ZIP code. 121 pharmacies were surveyed. Availability and cost of 15 medications commonly used to treat infertility were obtained. Data were stratified by racial demographics and analyzed with Fishers exact test, ANOVA, or Chi-square test for trend. Reduced availability of Clomiphene citrate (CC) was observed in the Bronx pharmacies (79 vs. 89%, P<0.01), an area populated by >80% blacks and Hispanics. Choriogonadotropin alpha (CGa) was not available in the Bronx (0 vs. 15%, P<0.01). There was also a significant decrease in the trend for the availability of both CC and CGa when the percentage of blacks increased from 10 to >40% (53 vs. 33%, P<0.01) compared to no change for increasing percentage of whites. In contrast the availability of CGa was highest in areas with > 80% white compared to areas with >40% black or Hispanic (15 vs. 0%, P<0.01). Interestingly as the percentage of the black population increased the cost of CGa significantly decreased ($133 ± 14 vs. $99 ± 10, P<0.01) and there was also a trend for reduced CC costs. Racial disparities in infertility outcomes are linked to delayed treatment and referral patterns or inadequate access or utilization of subspecialty care. These data suggest disparities in the availability of commonly used medications but not increased cost may adversely affect compliance and contribute to suboptimal treatment and delayed referral to subspecialist.