Approximately 12% of U.S. women 15–44 years of age have difficulty getting or staying pregnant, and disparities in infertility prevalence and service use by race/ethnicity have been noted.^1–3 From 1982 to 2002, infertility, the inability to conceive after 12 months or more of unprotected intercourse, decreased in the United States among white non-Hispanic women, yet increased among black non-Hispanic women.^4,5 Furthermore, black non-Hispanic women of reproductive age were 80% more likely to report infertility,³ but 20% less likely to receive infertility services than their white counterparts.^6,7 Assisted reproductive technology (ART), procedures where eggs or embryos are handled outside of the body to establish a pregnancy, are costly infertility treatments seldom covered by health insurance and likely subject to disparities in access.⁸ This commentary reviews racial/ethnic differences in infertility prevalence and treatment, examines recent national ART utilization rates by race/ethnicity and presence of a state insurance mandate for infertility treatment, and discusses potential approaches for reducing disparities.

Racial/ethnic disparities in infertility prevalence have been documented and may be due to disparities in conditions known to cause infertility such as sexually transmitted infections (STIs). For instance, some racial/ethnic minorities report higher rates of STIs (including STIs leading to pelvic inflammatory disease) compared with non-Hispanic whites.^5,9–12 Additionally, delays in accessing infertility care have been described for some racial/ethnic groups.¹¹ For example, Asian/Pacific Islander (A/PI) and black non-Hispanic women reported longer durations of infertility⁴ and accessed ART at a later age compared with white non-Hispanic women.^13,14

There are also differences in infertility service use, the highest proportion of use occurring among older, college-educated white non-Hispanic women with incomes >300% above the poverty level.^15,16 In 1999–2000, the distribution of ART cycles in the United States varied by race/ethnicity with white non-Hispanic women accounting for 85.5% of cycles, followed by Hispanic (5.5%), black non-Hispanic (4.6%), and A/PI non-Hispanic (4.5%) women.^16,17 While data from 2004 to 2006 showed a higher percentage of ART cycles for A/PI women (9.8%) compared with black and Hispanic (both at 6.5%),¹⁸ more recent estimates are lacking.

Race/ethnicity is often linked with socioeconomic disparities in healthcare access,¹⁹ especially in the United States, where certain racial/ethnic groups may experience residential segregation into neighborhoods with less economic and educational opportunities.²⁰ Conversely, one study found that socioeconomic factors—but not race—were associated with use of fertility treatments, as women with higher levels of income and education spent more money on fertility treatments than those with lower levels.²¹ ART, the most costly infertility treatment, averages $12,400 per cycle and may require multiple cycles to achieve a live birth.⁸ With the median U.S. income at $53,657 in 2014,²² ART can impose a financial burden on couples, particularly if health insurance coverage is limited or nonexistent.^23,24

Insurance coverage of in vitro fertilization (IVF), a common ART treatment, is associated with higher utilization and improvements in practice and outcomes such as the transfer of fewer embryos and lower percentages of multiple births.²⁴ For instance, the difference in the proportion of women using IVF in the military between black non-Hispanic women and their white non-Hispanic counterparts was lower than the difference between the same two groups in the general U.S. population, suggesting that insurance coverage from the military may reduce disparities in access.¹⁶ Additionally, universal insurance coverage mandates requiring all private insurers provide coverage for IVF were found to expand access to IVF treatment, even after accounting for differences in socioeconomic status.²⁵ Currently, 15 states adopted mandates requiring some level of private insurance coverage for infertility services in the United States; however, only 8 states mandate coverage for IVF. The mandates vary, with some states restricting coverage to select infertility diagnoses or ages and some implementing coverage caps.⁴ Additionally, employers that self-insure are exempt from state mandates and can comprise much of the employed population.

While many studies on treatment utilization focus on the frequency of ART cycles performed, limited national studies of the ART utilization rate by race/ethnicity exist. Furthermore, many of these studies used older data and were limited by the high percentage of missing race/ethnicity values in ART surveillance data.²⁶ Therefore, we used 2014 data from the Centers for Disease Control and Prevention’s (CDC) National ART Surveillance System (NASS) to calculate the number of ART procedures per million women of reproductive age (15–44 years) (a proxy measure of ART utilization based on varying population sizes) for each racial/ethnic category of women. Denominators for these calculations were derived from U.S. Census data.^27,28 To address the high proportion (35.6%) of missing information, multiple data imputation was performed for race/ethnicity using SUDAAN’s HOTDECK procedure, under the assumption of missing at random.²⁹ We also calculated ART utilization by race/ethnicity for women living in eight states with mandated insurance coverage for IVF during 2014 (Arkansas, Connecticut, Hawaii, Illinois, Maryland, Massachusetts, New Jersey, and Rhode Island) and for states without such coverage.

In 2014, A/PI women had the highest number of ART procedures per million women 15–44 years (5883.0) of age followed by white non-Hispanic women (2888.4), whereas black non-Hispanic, Hispanic, and American Indian/Alaska Native non-Hispanic women had lower than the average U.S. ART utilization rates (1434.0, 996.7, 806.8, respectively). ART usage rates were higher in states with insurance coverage mandates for IVF than in states without such mandates, regardless of race/ethnicity (Fig. 1).

Affordability may help explain the higher ART utilization rate among A/PI women. According to 2014 U.S. income data, the A/PI population was the highest earning race/ethnic group with a median income of $74,297²² and had the highest educational attainment compared with other race/ethnic groups.³⁰ Higher incomes may facilitate access to infertility services, and pursuit of higher education may contribute to childbearing later in life when fertility treatments are more likely to be needed.^31,32 Additionally, some evidence suggests that A/PI women may be affected by premature ovarian aging at higher rates than white women.³³

Although our results suggest that ART utilization was higher in states with IVF mandates regardless of race/ethnicity, in states with a mandate, utilization rates for black non-Hispanic and Hispanic women were still lower than the overall utilization rate for those states, a finding consistent with other studies.^34,35 This disparity may be due to out-of-pocket costs such as deductibles and copayments or factors beyond economics that may also provide barriers to care.^31,35 For example, certain racial/ethnic groups may delay accessing covered services due to cultural factors such as infertility stigma or fear of disappointing a partner.^4,36

The need to address disparities in ART utilization was recognized in the National Public Health Action Plan for the Detection, Prevention, and Management of Infertility; it calls for the provision and monitoring of effective infertility treatment services and/or prevention of conditions leading to infertility disparities.³⁷ Ensuring complete and accurate data collection on race/ethnicity in surveillance systems that monitor infertility and infertility treatments would aid future studies of disparities in risk factors for infertility and access to and utilization of safe and effective treatment.

Approaches to reduce disparities in access to infertility treatment could include provider incentives to practice in lower resource settings, provider education on appropriate and timely referrals to fertility specialists, and patient education about treatment funding options and lower cost care.^38,39 The American Society for Reproductive Medicine encourages providers to offer low-cost infertility treatments to reduce disparities in access.³⁸ Furthermore, including infertility diagnosis and evaluation services within health department STI and Title X clinics⁴⁰ may facilitate earlier diagnosis and infertility care seeking. Evaluation of infertility prevention programs, such as the CDC’s Infertility Prevention Project⁴¹ or educational efforts aimed at improving ART outcomes in cities and states,⁴² may identify effective evidence-based strategies that could help reduce disparities in infertility and its treatment. Additional studies could assess racial/ethnic disparities in cultural and social stigmas surrounding infertility, such as perceived bias from providers, and their impact on ART utilization.^{18,31,36,43,44} Burdens from the indirect costs of infertility treatment, such as missed work days and transportation to undergo treatments, could also be assessed.

In summary, recent 2014 data showing high ART utilization for A/PI women and lower ART utilization for other minority women point to continued disparities in infertility treatment. While insurance coverage may increase access and address some or all of the cost barriers, strategies that address other cost and noncost factors may be needed to help eliminate utilization disparities. It is important to continue to document, prevent, and reduce racial/ethnic disparities in infertility and access to care.