Who Seeks an Infertility Evaluation?
April 1, 2016
By Robert W. Rebar, MD
Professor and Chair, Department of Obstetrics and Gynecology, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI
Dr. Rebar reports no financial relationships relevant to this field of study.
Synopsis: Demographic and lifestyle factors influence who receives a fertility evaluation.
Source: Farland LV, et al. Who receives a medical evaluation for infertility in the United States? Fertil Steril 2016; Doi:/10.1016/j.fertnstert.2015.12.132.
Data from the National Survey for Family Growth have estimated that among women with fertility problems, less than half have ever sought any type of infertility care.1 Is this true for a population of women who work in healthcare? By exploring the attitudes of such a population, is it possible to better understand who does and who does not seek infertility services despite an inability to become pregnant?
Using data from the Nurses’ Health Study II, researchers in Boston identified a number of demographic and lifestyle factors associated with whether a woman having trouble getting pregnant obtains medical assistance. This study began in 1989 when 116,430 female registered nurses between the ages of 25 and 42 years returned a mailed questionnaire on their health and lifestyles. Every 2 years thereafter they answered a follow-up questionnaire, with about 92% of the original group continuing to participate. In each questionnaire from 1989 to 2001, and again in 2005 and 2009, the nurses were asked “if they had tried to become pregnant for more than one year without success.” They were also asked the cause of their infertility. The questionnaire permitted them to select from any of several different diagnoses, report multiple diagnoses, state the cause of their infertility was not determined, or report that the infertility was not investigated.
Of the women in the study, 7422 reported experiencing infertility after the first questionnaire cycle. About 65% of the women reporting infertility also reported having an infertility evaluation, significantly higher than the population at large, but still relatively low. The mean age at first report of infertility was 35.1 ± 4.7 (standard deviation) years among those who reported medical evaluation for infertility and 36.2 ± 4.7 years among those who did not.
Several factors appeared to play a role in predicting whether a woman would obtain a medical evaluation of her infertility. Women who lived in states with comprehensive insurance coverage (relative risk [RR], 1.09; 95% confidence interval [CI], 1.00-1.19) or who had a higher household income (P = 0.05 for linear trend) were more likely to report receiving an infertility evaluation. Compared with infertile women who had not reported a physical examination before their infertility, women who had a general physical examination within 2 years of their infertility (RR, 1.14; 95% CI, 1.06-1.22) or an examination for symptoms of any health condition (RR, 1.15; 95% CI, 1.06-1.24) were more likely to report having a fertility evaluation.
Several demographic factors also were important in determining the likelihood that an infertile woman was evaluated for infertility. Older women (P < 0.001 for linear trend) and parous women (RR, 0.81; 95% CI, 0.78-0.84) were less likely to undergo an infertility evaluation. Women whose male partners had graduate level education compared to those who had less than a 4-year college degree were more likely to undergo evaluation (P < 0.001 for linear trend). No significant difference was observed by race or marital status. Whereas infertile women who ever had an ultrasound or uterine fibroids were not more or less likely to report a medical evaluation, those with a history of surgically confirmed endometriosis were more likely to report having a medical evaluation than infertile women without documentation of previous endometriosis (RR, 1.27; 95% CI, 1.20-1.35).
Lifestyle choices were also important. Women who exercised frequently (P = 0.04 for linear trend) and took multivitamins (RR, 1.03; 95% CI, 1.00-1.07) were more likely to undergo a medical infertility evaluation. Current smokers (RR, 0.89; 95% CI, 0.83-0.96) and those with a higher body mass index (P = 0.01 for trend) were less likely to report receiving a medical infertility evaluation. Alcohol intake was unrelated to infertility diagnosis.
COMMENTARY
This study confirms the findings from other studies while simultaneously expanding our understanding of what compels couples to seek medical evaluation for infertility. Even among a group of individuals with a high degree of medical knowledge, as well as a professional connection to the medical system, many couples choose not to seek medical assistance for infertility. Although there must be a host of subtle individual factors in play, it is clear that it is possible to identify some factors that make it more likely for a couple to seek assistance.
Even after adjusting for confounding, “demographic” (age at infertility, parity, partner’s education) and “access” (income, insurance status, connection with the medical system) characteristics were significant predictors of reporting having received an infertility evaluation. The importance of insurance coverage becomes apparent when we consider that women in most European countries are more than twice as likely as American women to undergo cycles of in vitro fertilization. In the United States, women are much more likely to undergo in vitro fertilization in those states mandating some insurance coverage.
Historically, it is just such “demographic” and “access” characteristics that have been viewed as the major barriers to infertility care. This study suggests that other lifestyle factors play important roles as well. Clearly, individuals more concerned with living what they perceive as a “healthy lifestyle” and those who are more apt to seek medical care sought infertility care more frequently. Given the strong correlation between endometriosis and infertility, it is not surprising that women with a diagnosis of endometriosis were more apt to seek evaluation for infertility.
Failure to detect any racial or marital differences in this study may well be related to the highly educated and homogeneous population studied. Given the obvious socioeconomic disparities among ethnic groups in the United States, it is likely that these factors are more important in considering the United States population in its totality.
The authors suggested that the results of this study can help individual practitioners identify women who might benefit from an infertility investigation. Given that the Centers for Disease Control and Prevention recently stated that the detection of infertility and management of infertility care are national public health priorities,2 it behooves all first-line healthcare providers to be cognizant of the reticence of many women and couples to seek infertility care.
REFERENCES
- Chandra A, et al. Infertility and impaired fecundity in the United States, 1982-2010: Data from the National Survey of Family Growth. In: National Health Statistics Reports. 67th ed. Hyattsville, MD: National Center for Health Statistics. Available at http://www.cdc.gov/nchs/data/nhsr/nhsr067.pdf; 2013.
- Macaluso M, et al. A public health focus on infertility prevention, detection, and management. Fertil Steril 2010;93:16.e1-10.
Demographic and lifestyle factors influence who receives a fertility evaluation.
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