The impact of socioeconomic status on bulk semen parameters, fertility treatment, and fertility outcomes in a cohort of subfertile men

Abstract

To study the effect of socioeconomic status on the use of fertility treatment and the rate of live birth in men with subfertility. A retrospective, time-to-event analysis of men with subfertility in Utah stratified by socioeconomic status. Patients seen in fertility clinics throughout Utah. All men in Utah undergoing semen analysis between 1998 and 2017 at the state's 2 largest health care networks. Socioeconomic status (defined as area deprivation index of patients' residential location). Categorical use of fertility treatment, the count of fertility treatments (in patients with ≥1 treatment), and live birth after semen analysis. When controlling for age, ethnicity, and semen parameters (count and concentration), men from low socioeconomic areas were only 60%-70% as likely to use fertility treatment depending on type compared with men from high socioeconomic areas (intrauterine insemination [IUI] hazards ratio [HR] = 0.691 (0.581-0.821), P<.001; invitro fertilization [IVF] HR = 0.602 (0.466-0.778), P<.001). Of men undergoing fertility treatment, those from low socioeconomic areas had 75%-80% the number of treatments as men from high socioeconomic areas depending on type (IUI incident rate ratio = 0.740 (0.645-0.847), P<.001; IVF incident rate ratios = 0.803 (0.585-1.094), P=.170). When controlling for age, ethnicity, semen parameters, and use of fertility treatment, men from low socioeconomic areas were only 87% as likely to experience a live birth as men from high socioeconomic areas (HR = 0.871 (0.820-0.925), P<.001). Given the overall higher likelihood of live birth in men from high socioeconomic areas, as well as their greater chance of using fertility treatment, we predicted an annual disparity of 5 additional live births in high socioeconomic men compared with low for every 100 men. Men from low socioeconomic areas undergoing semen analyses are significantly less likely to use fertility treatment and experience a live birth than their counterparts from high socioeconomic areas. Mitigation programs to increase access to fertility treatment may help to reduce this bias; however, our results suggest that additional discrepancies beyond fertility treatment require addressing.