Assessment of a Decade of Change in U.S. Assisted Reproductive Technology Cumulative Live-Birth Rates: 2004-2009 Compared With 2014-2020.

OBJECTIVE: To assess the effects of demographic shifts, changes in contemporaneous clinical practices, and technologic innovation on assisted reproductive technology (ART) success rates by conducting an analysis of cumulative live-birth rates across different time periods, age groups, and infertility diagnoses. METHODS: We conducted a retrospective cohort study of autologous linked cycles comparing cumulative live-birth rates over successive cycles from patients undergoing their first retrieval between 2014 and 2019 in the SART CORS (Society for Assisted Reproductive Technology Clinic Outcome Reporting System) database. All cycles reported for these individuals up to 2020 were included for analysis. We compared cumulative live-birth rates stratified by age and infertility cause with published data from the 2004-2009 SART CORS database. RESULTS: From 2014 to 2019, 447,042 patients underwent their first autologous index retrieval, resulting in 1,007,374 cycles and 252,215 live births over the period of 2014 to 2020. In contrast, between 2004 and 2008, 246,740 patients underwent 471,208 cycles, resulting in 140,859 births by 2009. Noteworthy shifts in demographics were observed, with an increase in people of color seeking reproductive technology (57.9% vs 51.7%, P <.001). There was also an increase in patients with diminished ovarian reserve and ovulatory disorders and a decrease in endometriosis, tubal, and male factor infertility ( P <.001). Previously associated with decreased odds of live birth, frozen embryo transfer and preimplantation genetic testing showed increased odds in 2014-2020. Preimplantation genetic testing rose from 3.4% to 36.0% and was associated with a lower cumulative live-birth rate for those younger than age 35 years ( P <.001) but a higher cumulative live-birth rate for those aged 35 years or older ( P <.001). Comparing 2014-2020 with 2004-2009 shows that the overall cumulative live-birth rate improved for patients aged 35 years or older and for all infertility diagnoses except ovulatory disorders ( P <.001). CONCLUSION: This analysis provides insights into the changing landscape of ART treatments in the United States over the past two decades. The observed shifts in demographics, clinical practices, and technology highlight the dynamic nature of an evolving field of reproductive medicine. These findings may offer insight for clinicians to consider in counseling patients and to inform future research endeavors in the field of ART.

Effect of state insurance mandates on racial/ethnic disparities in the utilization and outcomes of donor oocyte-assisted reproductive technologies.

OBJECTIVE: To characterize racial/ethnic disparities in donor oocyte-assisted reproductive technology (ART) nationwide and examine the impact of state insurance mandates on disparities in utilization and outcomes. DESIGN: Retrospective cohort study. SETTING: Donor oocyte ART cycles in the United States (US). PATIENT(S): Women who underwent donor oocyte ART in 2014-2016, as reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System. INTERVENTION(S): Race/ethnicity of oocyte recipients. MAIN OUTCOME MEASURE(S): Live birth through 1 or more donor oocyte ART cycles in 2014-2016 per recipient. RESULT(S): We analyzed 44,033 donor ART cycles performed for 28,157 oocyte recipients, 99.2% (27,919/28,157) of whom were aged 25-54 years. Race/ethnicity data were reported for 61.4% (17,281/28,157) of the recipients. Among recipients aged 25-54 years with race data, 65.8% (11,264/17,128) identified as non-Hispanic White, whereas 58.9% were White among women aged 25-54 in the 2016 US census. In contrast, Black recipients comprised 8.3% of those aged 25-54 years with race data, compared with 13.7% nationwide. Among White recipients, 7.0% (791/11,356) lived in states with donor ART mandates (Massachusetts/New Jersey), compared with 6.5% (93/1,439) of Black recipients, 8.1% (108/1,335) of Hispanic recipients, and 5.8% (184/3,151) of Asian recipients. Black recipients had a higher median age and body mass index and were more likely to have uterine factor infertility. White recipients had the highest cumulative probability of live birth in the nonmandate (64.6%, 6,820/10,565) and mandate (69.5%, 550/791) states, followed by Asian recipients (nonmandate, 63.4% [1,881/2,967]; mandate, 65.2% [120/184]), Hispanic recipients (nonmandate, 60.5% [742/1,227]; mandate, 68.5% [74/108]), and Black recipients (nonmandate, 48.7% [655/1,346]; mandate, 48.4% [45/93]). The multivariable Poisson regression adjusting for donor's age and recipient's age, body mass index, nulliparity, history of recurrent pregnancy loss, diminished ovarian reserve, tubal factor and uterine factor infertility, prior ART treatment, use of preimplantation genetic testing, cumulative number of embryos transferred, use of blastocysts, and frozen-thawed transfers, demonstrated that Black recipients had a lower cumulative probability of a live birth than White recipients (relative risk [RR], 0.82; 95% confidence interval [CI], 0.77-0.87), as were Hispanic recipients (RR, 0.93; 95% CI, 0.89-0.99) and Asian recipients (RR, 0.96; 95% CI, 0.93-0.99). These disparities were not modified by state mandate for donor ART. CONCLUSION(S): State mandates for donor oocyte ART in their current forms are insufficient in decreasing racial/ethnic disparities.

State insurance mandates for in vitro fertilization are not associated with improving racial and ethnic disparities in utilization and treatment outcomes.

BACKGROUND: Racial and ethnic disparities in utilization and clinical outcomes following fertility care with in vitro fertilization in the United States are well-documented. Given the cost of fertility care, lack of insurance is a barrier to access across all races and ethnicities. OBJECTIVE: This study aimed to determine how state insurance mandates are associated with racial and ethnic disparities in in vitro fertilization utilization and clinical outcomes. STUDY DESIGN: This was a cohort study using data from the Society for Assisted Reproductive Technology Clinical Outcome Reporting System from 2014 to 2019 for autologous in vitro fertilization cycles. The primary outcomes were utilization-defined as the number of in vitro fertilization cycles per 10,000 reproductive-aged women-and cumulative live birth-defined as the delivery of at least 1 liveborn neonate resulting from a single stimulation cycle and its corresponding fresh or thawed transfers. RESULTS: Most (72.9%) of the 1,096,539 cycles from 487,191 women occurred in states without an insurance mandate. Although utilization was higher across all racial and ethnic groups in mandated states, the increase in utilization was greatest for non-Hispanic Asian and non-Hispanic White women. For instance, in the most recent study year (2019), the utilization rates for non-Hispanic White women compared with non-Hispanic Black/African American women were 23.5 cycles per 10,000 women higher in nonmandated states and 56.2 cycles per 10,000 women higher in mandated states. There was no significant interaction between race and ethnicity and insurance mandate status on any of the clinical outcomes (all P-values for interaction terms > .05). CONCLUSION: Racial and ethnic disparities in utilization of in vitro fertilization and clinical outcomes for autologous cycles persist regardless of state health insurance mandates.

Impact of in vitro fertilization state mandates for third party insurance coverage in the United States: a review and critical assessment.

The American Society for Reproductive Medicine estimates that fewer than a quarter of infertile couples have sufficient access to infertility care. Insurers in the United States (US) have long considered infertility to be a socially constructed condition, and thus in-vitro fertilization (IVF) an elective intervention. As a result, IVF is cost prohibitive for many patients in the US. State infertility insurance mandates are a crucial mechanism for expanding access to fertility care in the US in the absence of federal legislation. The first state insurance mandate for third party coverage of infertility services was passed by West Virginia in 1977, and Maryland passed the country's first IVF mandate in 1985. To date, twenty states have passed legislation requiring insurers to cover or offer coverage for the diagnosis and treatment of infertility. Ten states currently have "comprehensive" IVF mandates, meaning they require third party coverage for IVF with minimal restrictions to patient eligibility, exemptions, and lifetime limits. Several studies analyzing the impact of infertility and IVF mandates have been published in the past 20 years. In this review, we characterize and contextualize the existing evidence of the impact of state insurance mandates on access to infertility treatment, IVF practice patterns, and reproductive outcomes. Furthermore, we summarize the arguments in favor of insurance coverage for infertility care and assess the limitations of state insurance mandates as a strategy for increasing access to infertility treatment. State mandates play a key role in the promotion of evidence-based practices and represent an essential and impactful strategy for the advancement of gender equality and reproductive rights.

Differences in ICSI utilization rates among states with insurance mandates for ART coverage.

BACKGROUND: Assisted reproductive technology (ART) insurance mandates promote more selective utilization of ART clinic resources including intracytoplasmic sperm injection (ICSI). Our objective was to examine whether ICSI utilization differs by state insurance mandates for ART coverage and assess if such a difference is associated with male factor, preimplantation genetic testing (PGT), and/or live birth rates. METHODS: In this retrospective analysis of the Centers for Disease Control (CDC) data from 2018, ART clinics in ART-mandated states (n = 8, AR, CT, HI, IL, MD, MA, NJ, RI) were compared individually to one another and with non-mandated states in aggregate (n = 42) for use of ICSI, male factor, PGT, and live birth rates. ANOVA was used to evaluate differences between ART-mandated states and non-mandated states. Individual ART-mandated states were compared using Welch t-tests. Statistical significance was determined by Bonferroni Correction. RESULTS: There were significant differences in ICSI rates (%, mean ± SD) between MA (53.3 ± 21.3) and HI (90.7 ± 19.6), p = 0.028; IL (86.5 ± 18.7) and MA, p = 0.002; IL and MD (57.2 ± 30.8), p = 0.039; IL and NJ (62.0 ± 26.8), p = 0.007; between non-mandated states in aggregate (79.9 ± 19.9) and MA, p = 0.006, and NJ (62.0 ± 26.8), p = 0.02. Male factor rates of HI (65.8 ± 16.0) were significantly greater compared to CT (18.8 ± 8.7), IL (26.0 ± 11.9), MA (26.9 ± 6.6), MD (29.3 ± 9.9), NJ (30.6 ± 17.9), and non-mandated states in aggregate (29.7 ± 13.7), all p < 0.0001. No significant differences were reported for use of PGT and/or live birth rates across all age groups regardless of mandate status. CONCLUSIONS: ICSI use varied significantly among ART-mandated states while demonstrating no differences in live birth rates. These data suggest that the prevalence of male factor and the presence of a state insurance mandate are not the only factors influencing ICSI use. It is suggested that other non-clinical factors may impact the rate of ICSI utilization in a given state.

Disparities in ART Live Birth and Cumulative Live Birth Outcomes for Hispanic and Asian Women Compared to White Non-Hispanic Women.

BACKGROUND: Conflicting disparities have been seen in assisted reproductive technology (ART) outcomes for Hispanic and Asian women compared to white, non-Hispanic (WNH) women. We, therefore, sought to clarify these disparities and calculated cumulative live birth rates (CLBR) for these racial or ethnic groups using the SARTCORS database. METHODS: We performed an analysis of the 2014-2016 SARTCORS database for member clinics doing at least 50 cycles of ART each year. RESULTS: In comparison to cycles in WNH women, cycles in Hispanic and Asian patients were in older (p < 0.001), more nulliparous women, that were less likely to have a history of endometriosis compared WNH women regardless of prior ART status. ART cycles in Hispanic and Asian women, exhibited lower rates of live birth (LB) per cycle start (p < 0.001) compared to cycles in WNH women. Multivariate logistic regression demonstrated that cycles from Hispanic and Asian women were less likely to have a LB and CLBR than white women (OR 0.86; p = 0.004, OR 0.69; p < 0.001, respectively) independent of age, parity, BMI, etiology of infertility, use of ICSI or number of embryos transferred. CONCLUSIONS: Race or ethnicity continues to be an independent prognostic factor for LB and CLBR for ART. Additional analysis of trends among Hispanic and Asian women is warranted to enable addressing disparities in outcomes in ART treatment.

Psychological experience and coping strategies of patients in the Northeast US delaying care for infertility during the COVID-19 pandemic.

BACKGROUND: On March 17, 2020 an expert ASRM task force recommended the temporary suspension of new, non-urgent fertility treatments during an ongoing world-wide pandemic of Covid-19. We surveyed at the time of resumption of fertility care the psychological experience and coping strategies of patients pausing their care due to Covid-19 and examined which factors were associated and predictive of resilience, anxiety, stress and hopefulness. METHODS: Cross sectional cohort patient survey using an anonymous, self-reported, single time, web-based, HIPPA compliant platform (REDCap). Survey sampled two Northeast academic fertility practices (Yale Medicine Fertility Center in CT and Montefiore's Institute for Reproductive Medicine and Health in NY). Data from multiple choice and open response questions collected demographic, reproductive history, experience and attitudes about Covid-19, prior infertility treatment, sense of hopefulness and stress, coping strategies for mitigating stress and two validated psychological surveys to assess anxiety (six-item short-form State Trait Anxiety Inventory (STAl-6)) and resilience (10-item Connor-Davidson Resilience Scale, (CD-RISC-10). RESULTS: Seven hundred thirty-four patients were sent invitations to participate. Two hundred fourteen of 734 (29.2%) completed the survey. Patients reported their fertility journey had been delayed a mean of 10 weeks while 60% had been actively trying to conceive > 1.5 years. The top 5 ranked coping skills from a choice of 19 were establishing a daily routine, going outside regularly, exercising, maintaining social connection via phone, social media or Zoom and continuing to work. Having a history of anxiety (p < 0.0001) and having received oral medication as prior infertility treatment (p < 0.0001) were associated with lower resilience. Increased hopefulness about having a child at the time of completing the survey (p < 0.0001) and higher resilience scores (p < 0.0001) were associated with decreased anxiety. Higher reported stress scores (p < 0.0001) were associated with increased anxiety. Multiple multivariate regression showed being non-Hispanic black (p = 0.035) to be predictive of more resilience while variables predictive of less resilience were being a full-time homemaker (p = 0.03), having received oral medication as prior infertility treatment (p = 0.003) and having higher scores on the STAI-6 (< 0.0001). CONCLUSIONS: Prior to and in anticipation of further pauses in treatment the clinical staff should consider pretreatment screening for psychological distress and provide referral sources. In addition, utilization of a patient centered approach to care should be employed.

Status of racial disparities between black and white women undergoing assisted reproductive technology in the US.

BACKGROUND: Numerous studies have demonstrated substantial differences in assisted reproductive technology outcomes between black non-Hispanic and white non-Hispanic women. We sought to determine if disparities in assisted reproductive technology outcomes between cycles from black non-Hispanic and white non-Hispanic women have changed and to identify factors that may have influenced change and determine racial differences in cumulative live birth rates. METHODS: This is a retrospective cohort study of the SARTCORS database outcomes for 2014-2016 compared with those previously reported in 2004-2006 and 1999/2000. Patient demographics, etiology of infertility, and cycle outcomes were compared between black non-hispanic and white non-hispanic patients. Categorical values were compared using Chi-squared testing. Continuous variables were compared using t-test. Multiple logistic regression was used to assess confounders. RESULTS: We analyzed 122,721 autologous, fresh, non-donor embryo cycles from 2014 to 2016 of which 13,717 cycles from black and 109,004 cycles from white women. The proportion of cycles from black women increased from 6.5 to 8.4%. Cycles from black women were almost 3 times more likely to have tubal and/or uterine factor and body mass index ≥30 kg/m2. Multivariate logistic regression demonstrated that black women had a lower live birth rate (OR 0.71;P < 0.001) and a lower cumulative live birth rate for their initial cycle (OR 0.64; P < 0.001) independent of age, parity, body mass index, etiology of infertility, ovarian reserve, cycle cancellation, past spontaneous abortions, use of intra-cytoplasmic sperm injection or number of embryos transferred. A lower proportion of cycles in black women were represented among non-mandated states (P < 0.001) and cycles in black women were associated with higher clinical live birth rates in mandated states (P = 0.006). CONCLUSIONS: Disparities in assisted reproductive technology outcomes in the US have persisted for black women over the last 15 years. Limited access to state mandated insurance may be contributory. Race has continued to be an independent prognostic factor for live birth and cumulative live birth rate from assisted reproductive technology in the US.

Do state insurance mandates alter ICSI utilization?

BACKGROUND: Assisted reproductive technology (ART) insurance mandates resulted in improved access to infertility treatments like intracytoplasmic sperm injection (ICSI). Our objective was to examine whether ART insurance mandates demonstrate an increased association with ICSI use. METHODS: In this retrospective cohort study, clinic-specific data for 2000-2016 from the Centers for Disease Control (CDC) were grouped by state and subgrouped by the presence and extent of ART state insurance mandates. Mandated (n = 8) and non-mandated (n = 22) states were compared for ICSI use and male factor (MF) infertility in fresh non-donor ART cycles with a transfer in women < 35 years. Clinical pregnancy (CPR), live birth (LBR) rates, preimplantation genetic testing (PGT), elective single-embryo transfer (eSET) and twin birth rates per clinic were evaluated utilizing Welch's t-test. Pearson correlation was used to measure the strength of association between MF and ICSI; ICSI and CPR, and ICSI and LBR over time. Results were considered statistically significant at a p-value of < 0.05, with Bonferroni correction used for multiple comparisons. RESULTS: From 2000 to 2016, ICSI use per clinic increased in both mandated and non-mandated states. ICSI use per clinic in non-mandated states was significantly greater from 2011 to 2016 (p < 0.05, all years) than in mandated states. Clinics in mandated states had less MF (30.5 ± 15% vs 36.7 ± 15%; p < 0.001), lower CPR (39.8 ± 4% vs 43.4 ± 4%; p = 0.02) and lower LBR (33.9 ± 3.5% vs 37.9 ± 3.5%; p < 0.05). PGT rates were not significantly different. ICSI use in non-mandated states correlated with MF rates (r = 0.524, p = 0.03). A significant correlation between ICSI and CPR (r = 0.8, p < 0.001) and LBR (r = 0.7, p < 0.001) was noted in mandated states only. eSET rates were greater and twin rates were lower in mandated compared with non-mandated states. CONCLUSIONS: There was greater use of ICSI per clinic in non-mandated states, which correlated with an increased frequency of MF. In mandated states, lower ICSI rates per clinic were accompanied by a positive correlation with CPR and LBR, as well as a trend for greater eSET rates and lower twin rates, suggesting that state mandates for ART coverage may encourage more selective utilization of laboratory resources.

National survey of the Society for Assisted Reproductive Technology membership regarding insurance coverage for assisted reproductive technologies.

OBJECTIVE: To assess the attitudes of Society for Assisted Reproductive Technology (SART) members regarding expanding insurance coverage for patients seeking assisted reproductive technologies (ART) and identify some of the factors that may influence such attitudes. DESIGN: An anonymous online 14-question survey of SART membership; 1,556 surveys were sent through the SART Research Portal from June to December 2017. Questions were incremental in scope, beginning with expanding insurance coverage for ART for vulnerable populations (e.g., fertility preservation for cancer, couples with same recessive gene, fertility preservation for transgender individuals) to extending coverage to include patients who were uninsured for ART. Additional questions assessed attitudes about assuming some fiscal responsibility if mandated insurance were contingent on elective single-embryo transfer (eSET) and lower charges in anticipation of increased number of cases. SETTING: Not applicable. PATIENT(S): Not applicable. INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): Specific response to 14 survey questions. RESULT(S): The overall response rate was 43.4% (675/1,556). A large majority (>95%) favored insurance for fertility preservation for cancer patients and for avoidance of genetic disorders; 62.3% were supportive of infertility insurance coverage for transgender patients; 78% supported expanding insurance for the broadest segment of the general uninsured population; 76.7% supported expanding insurance contingent on eSET; and 51.3% would consider expanding insurance contingent on lowering charge per cycle in general, but only 23% responded as to what lower charge would be acceptable. Three of four factors were shown by multivariable logistic regression to be predictive of attitudes willing to expand insurance: practice setting (academic > hybrid > private), practicing in a mandated state, and higher annual volume of cases (>500 cycles); these had significant increased adjusted odds ratios ranging from 1.7 to 2.9. A fourth factor, the professional role one had in the practice, was not found to be of significant predictive value. CONCLUSION(S): The great majority of respondents were supportive of expanding insurance for specific segments of vulnerable populations with special needs and for the population who are presently uninsured. Furthermore, the majority of respondents would consider expanding insurance coverage contingent on age-appropriate eSET but have concerns about reduced reimbursement. Those most likely to be willing to expand insurance are those who practice in an academic setting or a mandated state and/or have a high annual volume of cases.

Direct vitamin D3 actions on rhesus macaque follicles in three-dimensional culture: assessment of follicle survival, growth, steroid, and antimüllerian hormone production.

OBJECTIVE: To investigate the direct actions of active 1,25-dihydroxy vitamin D3 (VD3) upon primate follicular development at specific stages of folliculogenesis. DESIGN: Secondary preantral follicles were isolated from rhesus monkeys ovaries, encapsulated in alginate, and cultured for 40 days. Follicles were randomly assigned to experimental groups of control, low-dose VD3 (LVD3; 25 pg/mL), and high-dose VD3 (HVD3; 100 pg/mL). SETTING: National primate research center. ANIMAL(S): Adult, female rhesus macaques (Macaca mulatta). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Follicle survival and growth, as well as oocyte size, were assessed. Progesterone (P4), androstenedione (A4), E2, and antimüllerian hormone (AMH) concentrations in culture media were measured. RESULT(S): Compared with the control group, LVD3 increased preantral follicle survival at week 2 by >66%, while HVD3 increased antral follicle diameters at week 5. Follicles with diameters ≥500 µm at week 5 were categorized as fast-growing follicles. Higher percentages of fast-growing follicles were obtained after HVD3 treatment. Although P4, A4, and E2 production by antral follicles was not altered by VD3, AMH concentrations were 36% higher in the LVD3 group relative to controls at week 5. Oocytes with larger diameters were retrieved from antral follicles developed in both LVD3 and HVD3 groups compared with controls. CONCLUSION(S): The addition of LVD3 increased preantral follicle survival and maintained AMH production by antral follicles, while HVD3 improved antral follicle growth. VD3 supplement promoted oocyte growth in in vitro-developed follicles. Direct actions of VD3 on the primate follicle appear to be both dose and stage dependent.

Diagnosis and treatment of diminished ovarian reserve in assisted reproductive technology cycles of women up to age 40 years: the role of insurance mandates.

OBJECTIVE: To explore correlates of diminished ovarian reserve (DOR) and predictors of assisted reproductive technologies (ART) treatment outcome in DOR cycles using the Society for Assisted Reproductive Technologies-Clinical Outcomes Reporting System (SART-CORS) database; we hypothesized that mandated state insurance coverage for ART is associated with the prevalence of DOR diagnosis in ART cycles and with treatment outcomes in DOR cycles. DESIGN: Cross-sectional study using ART cycles between 2004 and 2007. SETTING: Not applicable. PATIENT(S): A total of 182,779 fresh, nondonor, initial ART cycles in women up to age 40 years. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Prevalence of DOR and elevated FSH, odds ratio of DOR and elevated FSH in ART mandated vs. nonmandated states, live birth rates. RESULT(S): Compared with cycles performed in states with mandated ART coverage, cycles in states with no ART mandate were more likely to have DOR (adjusted odds ratio 1.43, 95% confidence interval 1.37-1.5) or elevated FSH (adjusted odds ratio 1.69, 95% confidence interval 1.56-1.85) as the sole reason for treatment. Lack of mandated ART coverage was associated with increased live birth rates in cycles diagnosed as DOR, but not in cycles characterized only by an elevated FSH. CONCLUSION(S): A significant association was observed between lack of mandated insurance for ART and the proportion of cycles treating DOR or elevated FSH. The presence or absence of state-mandated ART coverage could impact access to care and the mix of patients that pursue and initiate ART cycles in ways that influence these proportions. Additional studies are needed that consider the coalescence of insurance mandates, patient and provider factors, and state-level variables on the odds of specific infertility diagnoses and treatment prognosis.

Cultural factors contributing to health care disparities among patients with infertility in Midwestern United States.

OBJECTIVE: To identify cultural differences in access to infertility care. DESIGN: Cross-sectional, self-administered survey. SETTING: University hospital-based fertility center. PATIENT(S): Thirteen hundred fifty consecutive women who were seen for infertility care. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Details about demographic characteristics, health care access, and treatment opinions based on patient race or ethnicity. RESULT(S): The median age of participants was 35 years; 41% were white, 28% African American, 18% Hispanic, and 7% Asian. Compared with white women, African American and Hispanic women had been attempting to conceive for 1.5 years longer. They also found it more difficult to get an appointment, to take time off from work, and to pay for treatment. Forty-nine percent of respondents were concerned about the stigma of infertility, 46% about conceiving multiples, and 40% about financial costs. Disappointing one's spouse was of greater concern to African-American women, whereas avoiding the stigmatization of infertility was of greatest concern to Asian-American women. CONCLUSION(S): While the demand for infertility treatment increases in the United States, attention to cultural barriers to care and cultural meanings attributed to infertility should be addressed. Enhanced cultural competencies of the health care system need to be employed if equal access is to be realized as equal utilization for women of color seeking infertility care.

Trends of racial disparities in assisted reproductive technology outcomes in black women compared with white women: Society for Assisted Reproductive Technology 1999 and 2000 vs. 2004-2006.

OBJECTIVE: To determine trends in assisted reproductive technology (ART) in black and white women by comparing Society for Assisted Reproductive Technology (SART) database outcomes for 2004-2006 with previously reported outcomes for 1999 and 2000. DESIGN: Retrospective, cohort study. SETTING: The SART member clinics that performed at least 50 cycles of IVF and reported race in more than 95% of cycles. PATIENT(S): Women receiving 158,693 IVF cycles. INTERVENTION(S): In vitro fertilization using nondonor embryos. MAIN OUTCOME MEASURE(S): Live birth rate per cycle started. RESULT(S): Reporting of race increased from 52% to 60%. The proportion of black, non-Hispanic (BNH) women increased from 4.6% to 6.5%. For BNH women using fresh embryos and no prior ART, significant increasing trends were observed for older age, male factor, uterine factor, diminished ovarian reserve, and ovulation disorders. The BNH women were 2.5 times more likely to have tubal factor for those cycles with no prior ART. The proportion of live births per cycle started increased across all groups over time, although greater increases occurred for white women. CONCLUSION(S): There seems to be widening disparities in IVF outcomes between BNH and white women, perhaps attributable to poor prognostic factors among black women. Race continues to be a marker for prognosis for ART outcomes and should be reported.