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Objective: To investigate if differences in self-reported satisfaction with fertility clinics and doctors differ by race/ethnicity. Study Design: We used cross-sectional survey data from FertilityIQ online questionnaires completed by patients receiving U.S. fertility care from July 2015 to December 2020. Univariate and multivariate logistic and linear regression analyses performed to assess association of race/ethnicity on patient reported clinic and physician satisfaction. Results: Our total sample size included 21,472 patients (15,986 Caucasian, 1,856 Black, 1,780 LatinX, 771 East Asian, 619 South Asian, 273 Middle Eastern, 187 Native American self-reported). When adjusting for all confounders (demographic and patient satisfaction), we found that Black patients rated their doctors more highly (OR 1.30, 95% CI 1.04-1.62 p=0.022 logistic and Coef 0.082, 95% CI 0.013-0.15 p=0.02 linear), while other ethnic groups did not show significant differences compared to Caucasian patients. East Asians had borderline lower satisfaction with clinic satisfaction in logistic regression (OR 0.74 95% CI 0.55-1.00 p=0.05), while significant differences were not found for other ethnic groups for clinic satisfaction. Conclusions: In summary, some but not all minority groups differed in their self-reported perception of satisfaction with fertility clinic and doctors compared to Caucasian patients. Cultural differences towards surveys may contribute to some of these findings, and satisfaction by racial/ethnic group may also be modified by results of care.

To determine the prevalence of physical intimate partner violence (IPV) among postpartum women reporting preconception fertility treatment compared to those who conceived without the use of assisted reproduction.Cross-sectional population-based study.Twelve U.S. states with at least a 50% PRAMS survey response rate.Postpartum respondents of the Centers for Disease Control (CDC) Pregnancy Risk Assessment Monitoring System (PRAMS) survey.Preconception fertility treatment utilization.Physical Intimate Partner Violence (IPV).Of the 43,999 respondents included in this analytic sample, roughly 2% reported physical IPV. Respondents reporting preconception fertility treatment (12.6%) were less likely to endorse physical IPV than those who conceived without fertility treatment exposure (OR 0.5, 95% CI 0.4-0.7). In the multivariate regression model, the odds of physical IPV were similar among postpartum women regardless of fertility treatment exposure (aOR 1.2, 95% CI 0.8-2.0). Residing in a household with an income under the federal poverty level and increased preconception stressors were predictive of reported physical IPV. There was no difference in type of fertility treatment and report of physical IPV. Among women exposed to fertility treatment, predictors of physical IPV included self-identification of Black (p0.0001) or Hispanic (p=0.0352) race/ethnicity as well as report of 4 or more stressors in the 12 months prior to the most recent delivery (p0.0001).The use of fertility treatment did not confer greater risk of physical IPV within this postpartum population. However, there are many individuals with infertility who never present for an assessment, proceed with treatment, or are unsuccessful, thus the extent to which infertility and fertility treatment exposure is associated with physical IPV remains to be elucidated. Women reporting a greater number of stressors may be uniquely at risk despite access and exposure to fertility treatment. The preconception period, inclusive of encounters with infertility specialists, represents a unique opportunity to screen and counsel all women for IPV.

To determine the frequency of and factors associated with a patient being declined from pursuing a cycle of in vitro fertilization with autologous oocytes (IVF-AO). A cross-sectional study using a nationwide cohort of female respondents aged 35 or over, who visited a US fertility clinic from 1/2015 to 3/2020, responded to the online FertilityIQ questionnaire ( http://www.fertilityiq.com ). All respondents were asked if they were previously declined from pursuing a cycle of IVF-AO. Examined demographic and clinical predictors included age, race/ethnicity, education, income, clinic type, care received in a mandated state, insurance coverage for fertility treatment, and self-reported infertility diagnosis. Logistic regression was used to calculate the adjusted odds ratios for factors associated with being declined from pursuing IVF-AO. Of 8660 women who met inclusion criteria, 418 (4.8%) reported previously being declined a cycle of IVF-AO. In the multivariate analysis, predictors of being declined from pursuing IVF-AO included increasing age, income of less than $50,000, and diagnoses of poor oocyte quality and diminished ovarian reserve. Predictors of being less likely to report decline included some college or college degree and diagnoses of male factor, unexplained or tubal infertility. Notably, diagnosis of PCOS or residence in a state with mandated fertility coverage was not predictive of patients being declined from pursuing IVF-AO. Nearly 5% of patients who pursued IVF reported being declined from pursuing IVF-AO. Further studies are needed to confirm our findings and explore whether patients being declined treatment meet the criteria for futile or very poor prognosis.

Objective To conduct a comprehensive review of racial and ethnic health disparities in infertility care and treatment. Evidence Review Systematic literature searches were performed in PubMed and Embase from inception to April 2021. Studies were eligible for inclusion if they were original research performed in humans, observational study design, focused on circumstances contributing to infertility, access to infertility care, or outcomes of infertility treatment, and provided relevant information on racial or ethnic groups. Titles and abstracts were reviewed independently by two reviewers to identify pertinent articles. In addition, references of included articles were screened. Result(s) The PubMed search yielded 2,113 articles. An additional 2,301 articles were found in the Embase search. In total, 4,414 articles were screened on the basis of title and, where necessary, abstract. Thirty-four were found to meet the inclusion criteria and included in this review. Three additional studies were found from searching references of the included articles, resulting in 37 articles for discussion: 26 retrospective cohort studies, 2 prospective cohort studies, and 9 cross-sectional studies. The overall consensus in the literature is that reproductive health disparities on the basis of race and ethnicity impact fertility, access to care, and fertility treatment outcomes. Conclusion(s) Racial and ethnic differences in access to full-spectrum reproductive care, including infertility evaluation and treatment, remain. Despite access to infertility treatment, disparate treatment outcomes persist. Intrinsic and extrinsic factors, such as the institutionalization of racism and discrimination within medicine, remain influential in the diagnosis, care, and treatment outcomes of individuals with infertility. To address these inequities, we should mitigate provider bias, fund high-quality health disparity research, improve patient reproductive health knowledge, and advocate for increased access to treatment for all.

Race, as a social construct without a clear genetic underpinning, is frequently referenced in medicine as predictor of multiple diseases including that of infertility. The authors will discuss how systematic racism can have downstream consequences ranging from overt physician bias to use of medical algorithms that may potentiate the same disparities they attempt to narrow. Then, the authors explore the utility and pragmatic use of genetic ancestry to estimate disease prevalence, instead of racial categories. Finally, the authors explore how health inequities, rooted in systematic racism, can influence disease heritability effectively advocating for research to disentangle the contributions of racism to genetic susceptibility in infertility.

Objective To determine whether a machine learning causal inference model can optimize trigger injection timing to maximize the yield of fertilized oocytes (2PNs) and total usable blastocysts for a given cohort of stimulated follicles. Design Descriptive and comparative study of new technology. Setting Tertiary academic medical center. Patient(s) Patients undergoing IVF with intracytoplasmic sperm injection from 2008 to 2019 (n = 7,866). Intervention(s) Causal inference was performed with the use of a T-learner. Bagged decision trees were used to perform inference. The decision was framed as either triggering on that day or waiting another day. All patient characteristics and stimulation parameters on a given day were used to determine the recommendation. Main Outcome Measure(s) Average outcome improvement in total 2PNs and usable blastocysts compared with the physician’s decision. Result(s) For evaluation of average outcome improvement on 2PNs, the benefit of following the model’s recommendation was 3.015 (95% CI 2.626, 3.371) more 2PNs. For total usable blastocysts, the benefit was 1.515 (95% CI 1.134, 1.871) more usable blastocysts. Given that the physicians–model agreement was 52.57% and 61.89%, respectively, algorithm-assisted trigger decisions yield, on average, 1.430 more 2PNs and 0.577 more total usable blastocysts per stimulation. The most important features weighted in the model’s decision were the number of follicles 16–20 mm in diameter, the number of follicles 11–15 mm in diameter, and estradiol level, in that order. Conclusion(s) The use of this machine learning algorithm to optimize trigger injection timing may lead to a significant increase in the number of 2PNs and total usable blastocysts obtained from an IVF stimulation cycle when compared with physician decisions. Future research is required to confirm these findings prospectively.

Objective To evaluate whether physicians’ choice of ovarian stimulation protocol is associated with laboratory outcomes. Design Retrospective cohort study. Setting Single academic center. Patient(s) The subjects were 4,458 patients who completed more than one in vitro fertilization ovarian stimulation cycle within 1 year. On second stimulation, 49% repeated the same protocol and 51% underwent a different one. Intervention(s) Estradiol priming antagonist, antagonist +/– oral contraceptive pill priming, long luteal protocol, Lupron (Lupron [AbbVie Inc, North Chicago, IL]) stop protocol, and flare were compared. Logistic or linear regression with cluster robust standard errors to account for covariates and paired data was used. Main Outcome Measure(s) Oocytes collected (OC), fertilization rate, blastocyst progression (BP), usable embryos (UE), and euploid rate (ER). Result(s) First stimulation outcomes were comparable across all protocols for FR, BP, UE, and ER but were different for OC, after adjustment for covariates. For OC, the effect of switching protocols differed according to the type of the second stimulation. There was improvement in OC if the same stimulation was repeated, except for flare. In addition, there were slight, significant improvements in fertilization rate (difference in values or coefficient of 0.02; 95% confidence interval [CI], 0.004, 0.4) and UE (coefficient 1.25; 95% CI, 0.79, 1.72) when the same stimulation was repeated. There were no changes in BP (coefficient 0.03; 95% CI, –0.01, 0.08) or ER (coefficient 0.01; 95% CI, –0.04, 0.06) when protocols were changed. In a low-BP subgroup, greater improvement was seen when the same protocol was repeated (coefficient 0.03; 95% CI 0.01, 0.04). Conclusion(s) There was a slight but significant improvement in laboratory outcomes when the same stimulation protocol was repeated, so careful consideration should be made before switching stimulation protocols for the purpose of improving laboratory outcomes.

PURPOSE: This study aimed to determine the current percentage of United States (U.S.) assisted reproductive technology (ART) clinics offering sex selection via pre-implantation genetic screening (PGS) for non-medical purposes. METHODS: The authors conducted website review and telephone interview survey of 493 U.S. ART clinics performing in vitro fertilization (IVF) in 2017. Main outcome measures were pre-implantation genetic screening (PGS)/pre-implantation genetic diagnosis (PGD) practices and non-medical sex selection practices including family balancing. RESULTS: Of the 493 ART clinics in the USA, 482 clinics (97.8%) responded to our telephone interview survey. Among all U.S. ART clinics, 91.9% (n = 449) reported offering PGS and/or PGD. Furthermore, 476 clinics responded to survey questions about sex selection practices. Of those ART clinics, 72.7% (n = 346) reported offering sex selection. More specifically among those clinics offering sex selection, 93.6% (n = 324) reported performing sex selection for family balancing, and 81.2% (n = 281) reported performing for elective purposes (patient preference, regardless of rationale for the request). For couples without infertility, 83.5% (n = 289) of clinics offer sex selection for family balancing and 74.6% (n = 258) for non-specific elective reasons. CONCLUSIONS: The majority of U.S. ART clinics offer non-medical sex selection, a percentage that has increased substantially since last reported in 2006.

PURPOSE: To explore associations between infertility treatment and hypertensive disorders of pregnancy. METHODS: We collated multi-year as well as multi-state data from a national representative survey examining the association between self-reported infertility treatment (i.e., medication, intrauterine insemination, or assisted reproductive technology) and hypertensive disorders of pregnancy (i.e., high blood pressure, pregnancy-induced hypertension (PIH), preeclampsia, and toxemia). Data were analyzed using logistic regression. A total of 21,884 women in the United States (U.S.), from the Centers for Disease Control and Prevention’s (CDC) Pregnancy Risk Assessment Monitoring System (PRAMS) survey (2009–2015), participated in the study. RESULTS: In our analysis, 12.91% women reported a history of infertility treatment and 15.19% reported a history of hypertensive disorder of pregnancy. Compared with women who had never had infertility treatment, women who reported infertility treatment had 1.18 (adjusted OR, 95% confidence interval (CI) 1.05, 1.33) higher odds of reporting hypertensive disorder of pregnancy. Neither types of infertility treatment nor proximity of treatment to pregnancy were independently associated with hypertensive disorder of pregnancy. CONCLUSIONS: Our results suggest that among U.S. women, the treatment of infertility may be associated with hypertension disorder of pregnancy regardless of type of treatment.