Factors contributing to persistent disparate outcomes of in vitro fertilization treatment.

PURPOSE OF REVIEW: Disparate healthcare outcomes are ubiquitous and occur across all fields of medicine, specifically for racial and ethnic minorities. Within reproductive health, minority women face disparate access to care, particularly infertility services, poor outcomes of fertility treatment, alarmingly higher rates of maternal morbidity and mortality as well as higher rates of preterm birth, lower live birth rates when they conceive spontaneously or when they conceive with assisted reproductive technology. The objective of this review is to highlight factors contributing to the persistent racial/ethnic disparities in in vitro fertilization (IVF) outcomes. RECENT FINDINGS: Recent studies document poorer outcomes after IVF treatment. Black women have been shown to have lower live birth rates following IVF treatment for more than 15 years. SUMMARY: In an effort to better understand these negative outcomes, scientists and clinicians have investigated possible biological contributing factors including the vaginal microbiome, differences in oocyte quality, embryo viability, endometrial factors, and hormonal differences. Multiple social/cultural factors also play a role including access to care, particularly for people with low income, patient (mis)education, and medical racism/bias.

Comparison of sonohysterography to hysterosalpingogram for tubal patency assessment in a multicenter fertility treatment trial among women with polycystic ovary syndrome.

PURPOSE: To compare saline infusion sonohysterography (SIS) versus hysterosalpingogram (HSG) for confirmation of tubal patency. METHODS: Secondary analysis of a randomized controlled trial, Pregnancy in Polycystic Ovary Syndrome II (PPCOS II). Seven hundred fifty infertile women (18-40 years old) with polycystic ovary syndrome (PCOS) were randomized to up to 5 cycles of letrozole or clomiphene citrate. Prior to enrollment, tubal patency was determined by HSG, the presence of free fluid in the pelvis on SIS, laparoscopy, or recent intrauterine pregnancy. Logistic regression was conducted in patients who ovulated with clinical pregnancy as the outcome and HSG or SIS as the key independent variable. RESULTS: Among women who ovulated, 414 (66.9%) had tubal patency confirmed by SIS and 187 (30.2%) had at least one tube patent on HSG. Multivariable analysis indicated that choice of HSG versus SIS did not have a significant relationship on likelihood of clinical pregnancy, after adjustment for treatment arm, BMI, duration of infertility, smoking, and education (OR 1.14, 95% CI 0.77, 1.67, P = 0.52). Ectopic pregnancy occurred more often in women who had tubal patency confirmed by HSG compared to SIS (2.8% versus 0.6%, P = 0.02). CONCLUSIONS: In this large cohort of women with PCOS, there was no significant difference in clinical pregnancy rate between women who had tubal patency confirmed by HSG versus SIS. SIS is an acceptable imaging modality for assessment of tubal patency in this population.

Does elevated progesterone on day of oocyte maturation play a role in the racial disparities in IVF outcomes?

The aim of this study was to evaluate if premature progesterone elevation on the last day of assisted reproduction technique stimulation contributes to racial disparities in IVF outcome. A total of 3289 assisted reproduction technique cycles were evaluated in Latino, Asian, African American, and white women. Live birth was more likely in white women (42.6%) compared with Asian (34.8%) and African American women (36.3%), but was similar to Latino women (40.7%). In all racial groups, progesterone was negatively associated with live birth and the negative effect of progesterone persisted when adjusting for confounders. Although the effect of elevated progesterone was similar in all racial groups, the prevalence of elevated progesterone differed. Progesterone > 1.5 ng/ml occurred in only 10.6% of cycles in white women compared with 18.0% in Latino and 20.2% in Asian women. Progesterone > 2 ng/ml occurred in only 2.3% of cycles in white women compared with 6.3% in Latino, 5.9% in Asian and 4.4% in African American women. The increased prevalence of premature elevated progesterone persisted when controlling for IVF stimulation parameters. In conclusion, premature progesterone elevation had a negative effect on live birth in all racial groups studied. The prevalence of elevated progesterone was higher in racial minorities.

Assessing Racial Disparities in Access, Use, and Outcomes for Pregnant and Postpartum Veterans and Their Infants in Veterans Health Administration.

Objective: Limited population-based data examines racial disparities among pregnant and postpartum Veterans. Our objective was to determine whether Black/white racial disparities in health care access, use, and Veteran and infant outcomes are present among pregnant and postpartum Veterans and their infants using Veterans Health Administration (VA) care. Methods: The VA National Veteran Pregnancy and Maternity Care Survey included all Veterans with a VA paid live birth between June 2018 and December 2019. Participants could complete the survey online or by telephone. The independent variable was self-reported race. Outcomes included timely initiation of prenatal care, perceived access to timely prenatal care, attendance at a postpartum check-up, receipt of needed mental health care, cesarean section, postpartum rehospitalization, low birthweight, preterm birth, admission to a neonatal intensive care unit, and breastfeeding. Nonresponse weighted general linear models with a log-link were used to examine associations of race with outcomes. Cox regression was used to examine the association of race with duration of breastfeeding. Models adjusted for age, ethnicity, urban versus rural residence, and parity. Results: The analytic sample consisted of 1,220 Veterans (Black n = 916; white n = 304) representing 3,439 weighted responses (Black n = 1,027; white n = 2,412). No racial disparities were detected for health care access or use. Black Veterans were more likely than white Veterans to have a postpartum rehospitalization (RR 1.67, 95% CI: 1.04-2.68) and a low-birthweight infant (RR 1.67, 95% CI: 1.20-2.33). Conclusion: While no racial disparities were detected for health care access and use, we identified disparities in postpartum rehospitalization and low birthweight, underscoring that access is not sufficient for ensuring health equity.

The impact of coronavirus on reproduction: contraceptive access, pregnancy rates, pregnancy delay, and the role of vaccination.

It is important to closely examine trends in reproduction during a pandemic because it provides not only the foundation for an improved future response but also crucial insights regarding the disparate impact across different races and socioeconomic classes. The coronavirus disease 2019 pandemic is a prime example of the impact a pandemic can have on a nation's reproductive health. Contraception and abortion access became more difficult with more barriers to access, likely contributing to increasing unintended pregnancy rates. Underrepresented minorities and vulnerable populations were disproportionately affected by the virus on their reproductive health as well as by the virus itself. As the first ever messenger ribonucleic acid vaccine in conjunction with the lack of inclusion of pregnant and peripartum women in initial studies and conflicting and misinformation on social media, the initial role of the coronavirus disease 2019 vaccine in women of reproductive age was unclear. Further research inclusive of this group of women has led to the consensus by major medical societies to recommend vaccination of women regardless of pregnancy or lactating status. Examining these topics in depth will lead to the development of strategies that can be employed to mitigate the negative effects on reproductive health during the current pandemic and can also be applied to future strategic plans to prevent similar negative outcomes.

Uterine Weight as a Modifier of Black/White Racial Disparities in Minimally Invasive Hysterectomy Among Veterans with Fibroids in the Veterans Health Administration.

Introduction: Uterine fibroids are the most common indication for hysterectomy. Minimally invasive hysterectomy (MIH) confers lower risk of complications and shorter recovery than open surgical procedures; however, it is more challenging to perform with larger fibroids. There are racialized differences in fibroid size and MIH rates. We examined the role of uterine size in black-white differences in MIH among Veterans in the Department of Veterans Affairs (VA). Methods: Using VA clinical and administrative data, we conducted a cross-sectional study among black and white Veterans with fibroids who underwent hysterectomy between 2012 and 2014. We abstracted postoperative uterine weight from pathology reports as a proxy for uterine size. We used a generalized linear model to estimate the association between race and MIH and tested an interaction between race and postoperative uterine weight (≤250 g vs. >250 g). We estimated adjusted marginal effects for racial differences in MIH by postoperative uterine weight. Results: The sample included 732 Veterans (60% black, 40% white). Postoperative uterine weight modified the association of race and MIH (p for interaction=0.05). Black Veterans with postoperative uterine weight ≤250 g had a nearly 12-percentage point decrease in MIH compared to white Veterans (95% CI -23.1 to -0.5), with no difference by race among those with postoperative uterine weight >250 g. Discussion: The racial disparity among Veterans with small fibroids who should be candidates for MIH underscores the role of other determinants beyond uterine size. To eliminate disparities in MIH, research focused on experiences of black Veterans, including pathways to treatment and provider-patient interactions, is needed.

Understanding Variation in Availability and Provision of Minimally Invasive Hysterectomy: A Qualitative Study of Department of Veterans Affairs Gynecologists.

BACKGROUND: Approximately one-half of women undergoing hysterectomy in the Department of Veterans Affairs health care system receive minimally invasive hysterectomies (MIH), with Black women less likely than White women to receive MIH. We sought to characterize gynecologists' perspectives on factors contributing to the availability and provision of MIH and on the role of race/ethnicity in decision making. METHODS: Between October 2017 and January 2018, we conducted 16 in-depth semistructured telephone interviews with Department of Veterans Affairs gynecologists exploring practice characteristics and barriers and facilitators to providing MIH, including clinical and nonclinical characteristics of patients impacting surgical decision making. We identified key themes using simultaneous deductive and inductive thematic analysis. RESULTS: Gynecologists identified provider-, facility-, and patient-level barriers and facilitators to MIH. Provider-level factors included gynecologists' skills and training in MIH, and facility factors included access to qualified surgical assistants, availability of surgical equipment, and operating room resources, particularly time. On the patient level, clinical characteristics, including uterine size, were the most common determinants of surgical approach, but nonclinical factors such as patients' attitudes toward surgery also contributed. Race/ethnicity was identified by a minority of respondents as influencing hysterectomy route through clinical presentation and surgical attitudes. CONCLUSIONS: Given the range of factors identified, efforts to promote MIH in the Department of Veterans Affairs will likely require a multipronged approach that includes support for MIH training, increased access to surgical assistants with MIH skills, and reduced barriers to obtaining equipment. Patient perspectives are needed to more fully capture nonclinical patient-level contributors to MIH and differences in MIH between Black and White Veterans.

Is transferring a lower-quality embryo with a good-quality blastocyst detrimental to the likelihood of live birth?

OBJECTIVE: To determine if transferring a lower-quality embryo with a good-quality blastocyst is detrimental, given that evidence suggests that embryos can signal the endometrium and that embryo quality may affect negatively endometrial receptivity. DESIGN: Retrospective cohort study. SETTING: In vitro fertilization center. INTERVENTION(S): Single- versus double-embryo transfer. PATIENT(S): Patients with a double-embryo transfer of a good-quality blastocyst plus a lower-quality blastocyst, early blastocyst, or morula were compared with patients receiving a single good-quality blastocyst. MAIN OUTCOME MEASURE(S): Live birth, multiple gestation. RESULT(S): In this study, 4,640 in vitro fertilization cycles were analyzed. In none of the analyses did transferring a second lower-quality embryo negatively affect birth rate. In the primary analysis, transferring a second lower-quality embryo increased live birth by 10% and the multiple birth rate by 15%. The addition of a fair- or poor-quality blastocyst or early blastocyst markedly increased the twin birth rate by 22%-27% with an 8%-12% increase in live birth. The addition of a morula did not increase live birth but resulted in 12% more multiples. In women younger than 38 years, adding a lower-quality embryo increased the birth rate by 7% but resulted in 18% increase in multiples. In women 38 years or older, adding a lower-quality embryo increased the live birth rate by 9% with a 15% increase in multiples. CONCLUSION(S): Addition of a lower-quality embryo does not have a detrimental effect on a good-quality blastocyst and results in a small increase in live births. However, this is at the expense of a marked increase in the likelihood of multiple gestations.

Military Sexual Trauma and Sexual Health in Women Veterans: A Systematic Review.

INTRODUCTION: Sexual trauma during military service is prevalent among women veterans and is associated with multiple negative physical and mental health sequelae. The high prevalence of military sexual trauma (MST), sexual harassment and assault during military service, has prompted the Veterans Health Administration to enact several policies to address the detrimental health impacts of this experience. MST also negatively impacts veterans' sexual health, yet the field lacks a systematic review of the relationship between MST and sexual health among women veterans. AIM: To systematically review the existing research on the impact of MST on sexual health in women veterans. METHODS: The published literature examining MST and sexual health in women veterans prior to July 19, 2018, was reviewed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for systematic reviews. Articles were abstracted and evaluated for risk of bias. MAIN OUTCOME MEASURES: 6 articles were identified that met inclusion criteria; they generally evidenced a low risk of bias and thus a high quality of evidence. Results indicated that MST is associated with sexual dysfunction and low sexual satisfaction among women veterans. Other mental health concerns were also commonly comorbid with female sexual dysfunction in this population. This body of literature is small and methodologically limited by over-reliance on observational study design, use of non-validated and single-item measures of sexual health, and failure to comprehensively assess trauma history, including sexual and non-sexual trauma. CONCLUSIONS: Sexual dysfunction is a salient health issue for women veterans who experienced MST. Additional research is needed with improved designs, validated measures of sexual function, and comprehensive assessment of trauma to learn about the specific impact of MST on women veterans' sexual health. We present recommendations for future directions in terms of research, clinical practice, education, and policy. Pulverman CS, Christy AY, Kelly UA. Military Sexual Trauma and Sexual Health in Women Veterans: A Systematic Review. Sex Med Rev 2019;7:393-407.

Factors associated with the use of elective single-embryo transfer and pregnancy outcomes in the United States, 2004-2012.

OBJECTIVE: To evaluate factors associated with elective single-embryo transfer (eSET) utilization and its effect on assisted reproductive technology outcomes in the United States. DESIGN: Historical cohort. SETTING: Not applicable. PATIENT(S): Fresh IVF cycles of women aged 18-37 years using autologous oocytes with either one (SET) or two (double-embryo transfer [DET]) embryos transferred and reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System between 2004 and 2012. Cycles were categorized into four groups with ([+]) or without ([-]) supernumerary embryos cryopreserved. The SET group with embryos cryopreserved was designated as eSET. INTERVENTION(S): None. MAIN OUTCOMES MEASURE(S): The likelihood of eSET utilization, live birth, and singleton non-low birth weight term live birth, modeled using logistic regression. Presented as adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULT(S): The study included 263,375 cycles (21,917 SET[-]cryopreservation, 20,996 SET[+]cryopreservation, 103,371 DET[-]cryopreservation, and 117,091 DET[+]cryopreservation). The utilization of eSET (SET[+]cryopreservation) increased from 1.8% in 2004 to 14.9% in 2012 (aOR 7.66, 95% CI 6.87-8.53) and was more likely with assisted reproductive technology insurance coverage (aOR 1.60, 95% CI 1.54-1.66), Asian race (aOR 1.26, 95% CI 1.20-1.33), uterine factor diagnosis (aOR 1.48, 95% CI 1.37-1.59), retrieval of ≥16 oocytes (aOR 2.85, 95% CI 2.55-3.19), and the transfer of day 5-6 embryos (aOR 4.23, 95% CI 4.06-4.40); eSET was less likely in women aged 35-37 years (aOR 0.76, 95% CI 0.73-0.80). Compared with DET cycles, the likelihood of the ideal outcome, term non-low birth weight singleton live birth, was increased 45%-52% with eSET. CONCLUSION(S): Expanding insurance coverage for IVF would facilitate the broader use of eSET and may reduce the morbidity and healthcare costs associated with multiple pregnancies.

Unintended Pregnancy in the Military Health Care System: Who is Really at Risk?

Unintended pregnancy is a global issue and one that is reportedly to be higher in the military population. We sought to assess rates of unintended pregnancy among the active duty population in comparison to other military health care beneficiaries. Using a validated six-question survey, patients aged 18 to 42 were surveyed in five different clinics at three major tertiary hospitals from December 2013 to December 2014. Individual survey questions were scored 0, 1, or 2 and a total score was tabulated. A total score of 0 to 3 indicated unintended pregnancy, 4 to 9 indicated ambivalence toward pregnancy, and 10 to 12 indicated intended pregnancy. Subanalysis was performed on two survey questions specifically looking at pregnancy intentions. A total of 1,211 completed surveys were analyzed. Overall, 6.9% of all respondents had an unintended pregnancy compared to 23% of pregnancies in single active duty women. Single, active duty service members were more likely to indicate they did not intend to get pregnant or want a baby before becoming pregnant. Overall, the rate of unintended pregnancy among military health care beneficiaries is low. However, single active duty women are at significantly higher risk for unintended pregnancy and specifically targeted interventions should be implemented for this population.