O-82: Economics cannot always explain minority under-utilization of assisted reproductive technologies

Abstract

Some investigators have suggested that economic forces are the principal cause for racial disparity in healthcare utilization and outcomes with assisted reproductive technologies (ART). Most have focused on disparity between African American and Caucasian women. African American and Hispanic women each comprise 13% of reproductive age women in the United States. Due to higher fertility rates and higher average number of births per woman in this population, few studies have addressed impaired fertility in the Hispanic population. When ART is utilized, little is known regarding outcomes. The military healthcare system is an excellent model for the study of ART utilization and outcomes. Servicemembers can undergo infertility evaluation at no cost. Treatment, including ART, is low-cost and access to care is increased. The objective of this study was to examine ART utilization and outcomes in Hispanic women in a high quality ART program with fewer barriers to accessing care. Retrospective cohort study, University-based, military ART program IRB approved review of 2,650 cycles between 1999-2003. Women aged <42 years with FSH levels on day 3 or day 10 ≤ 12mIU/L who underwent first cycle, fresh, non-donor ART were included. Racial information was obtained from self-reported data contained in our IVF database or from Department of Defense (DoD) electronic medical records where race is also self-reported but independently verified. DoD demographic data was obtained through the Defense Manpower Data Center 2003 Demographic Report. Patients whose race was listed as “other” (n=70) were excluded from analysis. Racial information was only collected on the female partners. Primary outcome variable was clinical pregnancy. Student’s t-test, chi-square and Fisher exact test were used where appropriate. 1,457 patients met inclusion criteria. 56 patients (3.8%) had race listed as Hispanic. Hispanics comprise 9.0% of the DoD population (n=1,419,061) and were therefore under-represented in our ART population (P<0.0001). In contrast to previously reported differences in infertility diagnoses between African-American women and Caucasian women, there were no differences between Hispanic and Caucasian women with regard to infertility diagnoses (tubal factor, anovulation, endometriosis, unexplained, other). Hispanic women had an incidence of leiomyoma 16.1% (9/56 compared to 105/974 10.7% in Caucasian women, P=0.28). Age, day 3 FSH, ampules of gonadotropin, days of stimulation, peak estradiol, number of mature oocytes and number of embryos transferred did not differ significantly between these two populations. Clinical pregnancy rate (42.9% vs. 42.6%), live birth rate (33.9% vs. 35.8%), implantation rate (27.5% vs. 31%) and spontaneous abortion rate (20.8% vs. 15.9%) did not differ between Hispanic and Caucasian women. Utilization of ART services by Hispanic women was not increased when economic barriers to ART were minimized. Pregnancy outcomes with ART in Hispanic women were comparable to Caucasian women. This study suggests that utilization of ART services by Hispanic women is not primarily driven by economics, but other factors such as social and cultural influences may explain the disparity.