Division Director, REI
Stanford University Medical Center
Generally speaking, Latinx patients have less access to the medical system in the United States and suffer worse experiences.
The Agency for Healthcare Research and Quality published as recently as 2018 that “hispanics receive worse care than Whites for about 35% of quality measures.” These measures cover a wide range of facets and many pertain directly or indirectly to infertility. This broader failure of the healthcare system may explain some of the challenges Latinx patients face in the fertility treatment process.
In the United States, women or couples of LatinX heritage are as likely to experience fertility challenges as nearly any other group.
Below are data published in Fertility and Sterility from a survey of over 15,000 heterosexual married women under the age of 44. Nearly 8% reported a previous period of infertility of 12 months or longer.
After correcting for medical and socioeconomic factors, investigators concluded women and couples of LatinX heritage were 70% more likely to have fertility challenges than non-LatinX white peers.
However, according to a 2014 report from the U.S. Department of Health and Human Services, “Hispanic or Latina” patients used medical services to get pregnant at far lower rates.
Below are the percentage of women aged 25–44 with “current fertility problems”. Compared to their white peers, after correcting for multiple variables, LatinX women were 27% less likely to have ever used fertility services.
What’s more, the report shows when LatinX patients did receive fertility services, they were far less likely to receive more intensive interventions.
As we discussed, the reasons for this discrepancy are likely many and hard to disentangle. While investigators try and correct for socioeconomic factors, that can be easier said than done.
To look at the matter more closely, investigators looked at treatment utilization rates in Massachusetts, arguably the state with the most comprehensive “mandate” for insurance coverage, and thus placing the lowest financial burden on its people. Theoretically, studies in “mandated” states like Massachusetts help minimize confounders and variables like cost and affordability.
As you can see in the data below, only LatinX women recorded statistically significant lower rates of infertility utilization, which investigators labeled a “glaring disparity”.
Taking things a step further, investigators looked at treatment utilization rates at Walter Reed Army Hospital which “can be thought of as a surrogate for an equal access to care model.” Many barriers like access and cost are reduced and all active duty participants have passed English proficiency testing and graduated high school, correcting for more variables than the Massachusetts study.
Investigators recorded similar findings to the two above studies, noting utilization was “markedly less than expected if use was driven primarily by cost.”
As we covered in the first lesson, treatment success rates tend to vary by approach, as well as patient specific factors like age, diagnosis and more.
A fundamental question is whether LatinX patients experience different rates of success than other groups, most notably non-LatinX caucasian patients who make up the majority of fertility patients nationally and who are over-represented in advertised success rate data.
In the case of treatments like Clomid or letrozole or IUI, there’s little—if any—reliable data to compare. As for IVF, there is data, but it can be hard to interpret.
On one hand, investigators recorded a 13% lower rate of IVF success when combing through data from 140,000 cycles nationally from 2004–2006. On the other hand, investigators in the military study above found no disparity.
Each study has its trade-offs, and for the moment, it’s hard to say definitively if a disparity exists. Contrast this to studies on success rates for Black or African American patients which tend to more uniformly and emphatically show a disparity.
One area of difference that does appear throughout the literature is that historically patients of LatinX heritage were more likely to have multiple embryos transferred per transfer.
Below is an extreme example (4 or more embryos per transfer) from an admittedly earlier era when multiple embryo transfer was more common.
The possibility that LatinX patients are more likely to have multiple embryos transferred at once represents a risk since multiple gestation pregnancies can have an impact on the person carrying the pregnancy and the offspring, as you can see in the data below.
In many ways, transferring multiple embryos at once takes on needless risk since the odds of delivery are the same whether a patient has two embryos transferred at once or transfers one-at-a-time, undergoing a second transfer if the first does not work.
While a second transfer (should it be necessary) will cost more money, it’s important not to confuse the cost of an additional transfer (often $1,000 - $5,000) with the cost of an additional cycle (often $10,000 - $25,000).
In our experience, should you find yourself feeling pressed to transfer multiple-embryos-at-once for purely financial reasons, doctors and clinics may be open to providing a discount on a second transfer (again, should it be necessary).
Finally, we’d point out the near-term costs of an additional transfer tend to pale in comparison to the longer term costs of raising twins, and making accommodations should any malady develop.
We have a detailed course on the subject and decisions to be made, which you can find here. One subject the course touches on lightly, but that may be more pressing in the case of LatinX patients (some of whom may have had a Catholic upbringing), is the notion of choosing to freeze embryos that were not used in a first transfer.
It’s possible fertility patients will face the question of what to do with such embryos if they’ve met their family-building objectives and yet more embryos remain. It’s plausible the prospect of having to make such a decision influences whether patients pursue IVF or decide to transfer more embryos than they’d otherwise prefer. These can be delicate decisions and consulting medical and mental health professionals, as well as clergy educated on the matter, can be of use. At FertilityIQ, you’ll see we have a dedicated lesson on the options and trade-offs of various embryos decisions.