Less than half of US women with infertility receive treatment, while just 1 in 10 have a live birth, a study has found. In addition, the study’s authors said the disparities across the spectrum of fertility care are “striking.”

“Black, Hispanic, and socioeconomically disadvantaged women face the greatest barriers to successful [fertility] outcomes,” Theresa Boyer, MS, MSPH, and colleagues wrote. “These inequities may worsen as more restrictive fertility legislation emerges, highlighting the need for health systems and policymakers to prioritize equitable access to fertility care.”

Boyer is a PhD candidate in the Department of Epidemiology at Johns Hopkins Bloomberg School of Public Health in Baltimore.

Boyer and her colleagues applied a “cascade of care” framework to US population data on women aged between 20 and 44 years to determine the timeline of their infertility awareness, treatment access, and live birth outcomes. Race, ethnicity, education, insurance, and age were evaluated to determine disparities in care.

“The cascade of care framework offers a useful approach for quantifying burden and identifying critical points of attrition in health services delivery and has been widely applied to chronic conditions such as HIV, diabetes, and hypertension,” Boyer and her colleagues wrote.

For their cross-sectional investigation, Boyer and colleagues used datasets from the 1991-2020 World Health Organization’s (WHO’s) lifetime infertility prevalence, self-reported infertility and treatment access from the 2013-2020 National Health and Nutrition Examination Survey (NHANES; unweighted N = 444), and 355,289 US birth certificates for live births conceived by women aged 20-44 years after fertility treatment. These data were reported in the National Vital Statistics System (NVSS) between 2016 and 2021.

“Since this is weighted survey data, the weighted estimates represent all US women aged 20-44 years,” Boyer told Medscape Medical News.

In a meta-analysis of 30 different studies, including 11 from the US, Boyer and colleagues found that the WHO’s pooled lifetime infertility prevalence in high-income countries was estimated as 17.8% from 1991 to 2021. “This is the starting estimate used to calculate awareness, access to treatment, and live birth outcomes,” Boyer said.

Infertility awareness was estimated by dividing the proportion of US women aged 20-44 years who reported a history of infertility (NHANES) by the pooled lifetime infertility prevalence among women in high-income countries (WHO). Treatment access was calculated by multiplying the proportion of women with self-reported infertility who reported seeking medical care (NHANES) by the infertility awareness estimate.

To estimate live births following fertility treatment, the investigators divided the proportion of live births conceived using fertility treatment (NVSS) by the product of infertility prevalence and treatment access. This was then multiplied by the access-to-care value. The final stage of the cascade was live births among all women with infertility.

Also using NHANES data, the investigators examined differences in the fertility care cascade according to race and ethnicity, highest level of education obtained, health insurance, and age.

The overall prevalence of infertility among women aged 20-44 years was 11.9% in women with a mean age of 34 years, with no differences based on race and ethnicity, educational attainment, health insurance status, or income. Of this group, 13.1% self-identified as Black and 19.7% as Hispanic. However, the investigators found that higher education and private insurance were associated with increased treatment access and live birth.

Infertility awareness in these women was high at 70%, while only 39% had access to fertility treatment, with the number of live births around 10%. White women were 58.5% of those with infertility but had 72.5% of live births conceived using fertility treatments.

They also had a live birth rate of 13% post-fertility treatment.

Of Asian women, 17% had live births after fertility treatments. In Hispanic women, the live birth rate after fertility treatment was 4%, and for Black women, it was the lowest at 3%.

Women with an associate’s degree (42%) or a 4-year degree or more (49%) were much more likely to have accessed a medical professional than those with only a high school degree (22%). This disparity persisted with women with a college degree or more (20%) being far more likely to have a live birth than women with less than a high school education (1%).

“These differences are further compounded by delays in care, with Black, Hispanic, and Asian women waiting, on average, 2 years longer to seek treatment. Delayed access to care may contribute to diminished ovarian reserve, impairing the likelihood of successful treatment outcomes,” Boyer and colleagues wrote.

Consistent with prior data indicating infertility diagnosis and treatment increases with age, Boyer and colleagues’ study showed that infertility awareness and treatment use were lowest in women aged 20-29 years and highest in women aged 40-44 years. In the latter group, nearly 40% achieved a live birth using fertility treatment.

There are only 21 states that mandate third-party coverage for infertility services, and eligibility criteria for these services vary widely, the authors wrote. Further, they claimed, “The lack of insurance coverage for IVF [in vitro fertilization] has created an environment where approximately 30% of assisted reproductive technology cycles in the US occur at private equity-affiliated practices. Uncertainty remains regarding how this pattern of acquisition and ownership will impact the cost and outcomes of these procedures.”

“Our findings reveal substantial disparities across the fertility care cascade by race, ethnicity, educational attainment, and insurance status,” the investigators wrote.

“I do not think that the results of the study [will] generally change the approach that reproductive endocrinology physicians take in providing access to care,” Amanda Adeleye, MD, a reproductive endocrinology physician and the medical director of CCRM Fertility Clinic in Chicago, told Medscape Medical News. “However, increasing awareness of these issues in a specialist ob/gyn community may help physicians and other providers more carefully identify and refer patients with infertility.”

She also said that the study is not likely to help clinicians improve access to fertility treatments for their patients “unless they become aware of their own implicit biases and improve their referral practices.”

In addition, Adeleye found the metrics of the study problematic. “The [researchers] aimed to assess awareness using a denominator of the prevalence of infertility globally. However, the incidence of infertility changes with age. I suspect that the number of younger people (20-29 years) with infertility is lower than the 15%-18% number, and to some extent, if people in this age group aren’t ready to conceive yet, their lack of awareness about infertility isn’t as relevant,” Adeleye wrote.

“This would mean the denominator of affected individuals in this group is lower and the proportion of people in this age group who are aware is higher than what was presented. The converse is true for the 40 and over group. There are likely more than 15%-18% of people who are affected by infertility. The number may be closer to 25%-50% of women who are trying to have a baby. In this case, the denominator of affected women is larger, and the proportion of people that are aware of their infertility is lower. I’m not convinced that using the same baseline infertility rates for all groups will average out the awareness metric.”

Meanwhile, another expert, Sigal Klipstein, MD, said, “Physicians are acutely aware of these disparities.” Klipstein is a reproductive endocrinologist, also in Chicago.

“The solutions cannot be realized solely or predominantly at the level of the individual physician. Systemic approaches are critical to decreasing disparities,” Klipstein said. “The greatest benefits will be derived from financial approaches to improve access to insurance coverage, geographic approaches such as increasing the number of physicians in underserved areas, many of which are less populated, and social approaches such as encouraging minority populations to access care by decreasing stigma and providing education regarding the high chance of achieving a pregnancy with fertility treatment, particularly at younger ages.”

Klipstein also encouraged physicians to include discussions of fertility with their reproductive-aged patients during wellness checks.

The authors and Klipstein reported having no conflicts of interest. Adeleye disclosed being a medical advisor for Carrot (fertility benefits company), Frame (fertility care navigation), and Kompass Diagnostics (hormone testing), and a strategic advisor for Roon (patient education).