Socioeconomic and Racial/Ethnic Inequalities in Infertility Prevalence, Help-Seeking, and Help Received Since 1995.

BACKGROUND: In the United States, infertility and treatment for infertility are marked by racial/ethnic and socioeconomic inequalities. Simultaneously, biomedical advances and increased public health attention toward preventing and addressing infertility have grown. It is not known, however, whether the racial/ethnic and socioeconomic inequalities observed in infertility prevalence, help-seeking, or help received have changed over time. METHODS: Using National Survey of Family Growth data (1995 through 2017-2019 cycles), this study applied multivariable logistic regression with interaction terms to investigate whether and how racial/ethnic and socioeconomic inequalities in 1) the prevalence of infertility, 2) ever seeking help to become pregnant, and 3) use of common types of medical help (advice, testing, medication for ovulation, surgery for blocked tubes, and artificial insemination) have changed over time. RESULTS: The results showed persisting, rather than narrowing or increasing, inequalities in the prevalence of infertility and help-seeking overall. The results showed persisting racial/ethnic inequalities in testing, ovulation medication use, and surgery for blocked tubes. By contrast, the results showed widening socioeconomic inequalities in testing and narrowing inequalities in the use of ovulation medications. CONCLUSIONS: There is little evidence to suggest policy interventions, biomedical advances, or increased public health awareness has narrowed inequalities in infertility prevalence, treatment seeking, or use of specific treatments.

Self-Perceived Infertility is Not Always Associated with Having Fewer Children: Evidence from German Panel Data.

Proximate determinants theory considers infertility rates a risk factor for lower fertility rates, but the assumption that people who perceive infertility will have fewer children has not been tested. This study investigates the association of self-perceived infertility with the number of children people have had after 11 years. Infertility implies reduced chances of conception (rather than sterility), but people do not always consistently perceive infertility over time. If people who think they are infertile at one time can later report no infertility, then does self-perceived infertility necessarily lead to having fewer children? We answer this question by analyzing 11 waves of the German family panel (pairfam) data using negative binomial growth curve models for eight core demographic subgroups created by combinations of gender (men/women), parity (0/1+children), and initial age groups (25-27 and 35-37). Those who repeatedly perceived themselves to be infertile (three times or more) had fewer children than those who perceived themselves to be infertile once or twice in only four of eight gender by initial parity by age groups. Only in four groups did people who perceived themselves to be infertile once or twice have fewer children than those who never perceived themselves to be infertile in both the unadjusted and adjusted models. Thus, self-perceived infertility does not necessarily result in fewer children. Rather, the association depends upon life course context and gender.

Social and Emotional Loneliness: Their Relationship to Multiple Domains of Cognition in Later Life.

Despite the fact that the literature suggests loneliness to undermine cognitive functioning in later life, no work has simultaneously examined the relationships between these constructs taking a multidimensional approach to the assessment of each. The present study explored relationships among social and emotional loneliness and both general crystallized (Gc) and general fluid (Gf) ability, as well as to several indices of everyday intellectual functioning in later life. Sequential regression analyses suggested that neither social nor emotional loneliness predicted Gc. However, only when eliminating health as a covariate was more social loneliness associated with lower scores for Gf. Surprisingly, more emotional loneliness was associated with higher scores for Gf. More social loneliness also predicted more everyday cognitive failures and with less positive lifestyle attitudes. These findings support a view of loneliness-cognition relationships in later life that reflects the multidimensional nature of each construct.

From generalist to specialist: A qualitative study of the perceptions of infertility patients.

Few studies explore in-depth accounts of women's and men's experiences with, and transitions between, obstetrician/gynaecologists (OB/GYNs) and reproductive endocrinologists during infertility diagnostic and treatment processes. This study examined this subject matter with data from qualitative, in-depth, semi-structured interviews. Between April 2007 and March 2008, the first author interviewed 20 women and eight men from a large midwestern metropolitan area in the USA who had used, or were in the process of using, any fertility treatment in the 5 years preceding the interview. Six couples and 16 individuals were interviewed, resulting in narratives of 22 distinct infertility journeys. The main complaints made by respondents about OB/GYNs were that they were insufficiently concerned with providing timely treatment and that they paid insufficient attention to male partners. Women felt that their concerns were taken more seriously by reproductive endocrinologists, but complained of insensitivity, depersonalization and misinformation, and were suspicious of a profit orientation.

Is perceived inability to procreate associated with life satisfaction? Evidence from a German panel study.

Most studies of the psychosocial consequences of infertility have focused on those who seek medical treatment, leaving a research gap regarding the psychosocial consequences of perceived inability to procreate in the general population. Moreover, most studies are cross-sectional and the results are thus likely affected by omitted variable bias. Inspired by aspects of the Theory of Conjunctural Action, this study analysed 10 waves of data from the German Family Panel (pairfam) for women and men using fixed effects panel regression and including time-varying control variables suggested by theory and research. This study found that both women and men experienced lower life satisfaction in years when they perceived an inability to procreate. This association was not affected by the inclusion of relevant time-varying control variables. Furthermore, the association between perceived barriers to procreation and life satisfaction was found to differ depending on life circumstances and gender. Women with partners and men without partners had lower life satisfaction when they perceived an inability to procreate compared with when they did not. Women and men who intended to have a(nother) child had lower life satisfaction when they perceived an inability to procreate compared with when they did not. The association, however, was only significant for men. Somewhat surprisingly, women who perceived an inability to procreate also had lower life satisfaction when they were not intending to have a(nother) child. This study makes an important contribution to research on the psychosocial consequences of perceived infertility, and provides insights into why some people may pursue assisted reproductive technology for family creation.

Is Reproductive Orientation Associated with Sexual Satisfaction Among Partnered U.S. Women?

Little is known about how "reproductive orientation" (i.e., trying to get pregnant, ambivalent about pregnancy, trying to avoid pregnancy, or having had a sterilization surgery) is associated with sexual satisfaction among women of childbearing age. Using data from the National Survey of Fertility Barriers (N = 2811), we examined the association of reproductive orientation with sexual satisfaction, adjusting for relationship characteristics including union type (cohabitation versus marriage), quality, and length; infertility history; and demographic characteristics including age, parity, and race/ethnicity. Results indicated that women who were ambivalent or trying to get pregnant reported significantly higher levels of sexual satisfaction than women who were sterile in the unadjusted model, but not in the models that included relationship quality. The association of reproductive orientation and sexual satisfaction depended upon relationship quality; among women with lower relationship quality, "trying" was associated with higher, and among those with higher relationship quality, with lower sexual satisfaction.

Factors associated with medical help-seeking for infertility in developed countries: A narrative review of recent literature.

The reasons why people decide for or against seeking medical help for infertility are still far from clear. With advances in reproductive medicine, use of medically-assisted reproduction has increased over the last three decades. Over the same period, an appreciable amount of quantitative studies on the determinants of medical help-seeking for infertility has accumulated. However, to our knowledge this narrative review is the first to summarize and evaluate findings from these studies. This review includes 39 studies carried out in 11 countries, covering the period 1990-2019. We have identified five categories of determinants of help-seeking: socio-demographic variables, socio-economic factors, reproductive history, attitudes, and psychological factors. Each category consists of several variables. Considerable knowledge has accumulated on socio-economic variables, indicating that there is social inequality in access to treatments in several countries. Less is known about marital status, attitudes and psychological factors. Findings on the latter two mostly derive from two US surveys. Overall, the body of research appears heterogeneous and fragmented. Studies differ in central aspects of study design (definitions of the analysis sample and of help-seeking, type of analysis (bivariate or multivariate), set of variables included in multivariate studies) making comparisons of findings difficult. Low comparability is reinforced by country differences in the provision of treatment, legislation on access and treatment coverage. The majority of papers lack a theoretical foundation or reference to any theory. Using a theoretical framework to guide empirical research could help to overcome the problems described above. Single-country studies should include information on legal and cultural context. More studies from countries other than the US are needed as well as multi-country studies in order to develop a systematic understanding of how macro-level structures relate to decisions about medical help-seeking. This review should assist future researchers in their attempt to conduct studies on help-seeking for infertility.

On estimating the prevalence of use of medically assisted reproduction in developed countries: a critical review of recent literature.

BACKGROUND: Existing reviews on the prevalence of use of medically assisted reproduction (MAR) are relatively old and include mainly studies from the 1980s and 1990s. Since then, MAR has developed at a rapid pace, public awareness and acceptance of medical solutions to infertility problems has increased, and, consequently, the use of MAR has risen in developed countries. OBJECTIVE AND RATIONALE: This study provides a comprehensive overview of the state of research on the prevalence of MAR use in women and men, as well as a critique of methodology used in studies of the use of MAR, and suggestions for moving forward. SEARCH METHODS: Articles were located via the databases Academic Search Complete, Biomed Central, FirstSearch, Google Scholar, Medline, Health and Medical Collection, Medline and Social Science Citation Index using the key words 'infertile', 'infertility', 'subfecund', 'subfecundity', 'treatment', 'help-seeking', 'service use', 'service utilization', 'ART use' and 'MAR use' separately and in various combinations. The focus was on studies from developed countries, published between 1990 and 2018, in English, German or French. OUTCOMES: In this article, we have reviewed 39 studies covering 13 countries or regions; approximately half of these covered the USA. Ten studies were published in the 1990s, 10 in the 2000s and 19 since 2010. Studies report different types of prevalence rates such as lifetime and current prevalence rates of MAR use. Prevalence rates are based on very different denominators: women who tried to become pregnant for at least 12 months without success, women who experienced at least 12 months of unprotected intercourse without success, women of reproductive age from the general population or women with a life birth. There are few studies that report help-seeking rates for men or make direct comparisons between genders. Knowledge on medical help-seeking across different stages, such as seeing a doctor, undergoing tests, having operations to restore fertility or ART, has started to accumulate in recent years. There are conceptual reasons for being cautious about drawing conclusions about gender, regional, country level and differences over time in help-seeking rates. LIMITATIONS REASONS FOR CAUTION: In a narrative review, the risk of bias in the interpretation of findings cannot be completely eliminated. The literature search was limited to languages the authors speak: English, French and German. WIDER IMPLICATIONS: In line with earlier reviews, we found that studies on help-seeking are not comparable across time and space, preventing researchers and healthcare providers from understanding the relation between social change, social policy, social structure and help-seeking for infertility. The discussion in this article should assist future researchers in designing better studies on the prevalence of MAR use. We provide suggestions for producing better estimates of the prevalence of MAR use. More cross-country and cross-gender comparisons are needed. Studies that treat help-seeking as a continuum and report on different stages are preferable compared to choosing arbitrary cutoff points, as is common practice in the studies reviewed. STUDY FUNDING/COMPETING INTERESTS: None.

Is a dyadic stressor experienced as equally distressing by both partners? The case of perceived fertility problems.

Using data from a population survey, this article explores whether perceptions of having a fertility problem among 926 U.S. couples in heterosexual relationships (women aged 25-45 and male partners) are associated with distress. Most couples did not perceive a fertility problem (58%). In almost a third (30%) of the couples, only women perceived a fertility problem; in 4%, only the men; and in nearly a fifth (19%), both perceived a problem. Adjusted for characteristics associated with fertility problems and depressive symptoms, those who perceived a problem exhibited significantly more depressive symptoms than those who did not. Fertility problems are sometimes experienced as individual because in some couples only one partner perceives a problem or has higher distress in response to their own rather than to their partners' perceived problems. For women, fertility problems are experienced as a couple phenomenon because women were more distressed when both partners perceive a problem. The perception of fertility problems is gendered in that women were more likely to perceive a problem than men. Furthermore, men are most distressed when they perceive a problem and their partner does not.

Does Self-Identifying as Having a Health Problem Precede Medical Contact? The Case of Infertility.

Studies of medical help-seeking presume that self-identifying as having a health problem precedes medical contact, but this ordering of the identity-behavior relationship has not been systematically examined. We used longitudinal data from the National Survey of Fertility Barriers (2004 to 2010) on 412 women with infertility to document the temporal relationship between self-identifying as having a fertility problem and making medical contact. The symbolic interactionist perspective suggests that infertility will be perceived as identity disruption and that in response women will align self-identity and medical behavior over time. Cross-tabulation analysis indicated that more women do self-identify as having a fertility problem first (24 percent) as opposed to making medical contact first (5.5 percent). There was also a tendency toward aligning self-identification and behavior over time. Latent class analyses revealed six patterns: 1) consistently involved, 2) early consulters, 3) consistently uninvolved, 4) consistent perceivers, 5) medical dropouts, and 6) early perceivers. Strong fertility intent and primary infertility, two identity-relevant characteristics, had the strongest associations with latent class membership. The relationship between self-identification and medical help-seeking is thus dynamic and complex.

Degrees of Medicalization: The Case of Infertility Health-Seeking.

We examine responses to infertility among a sample of 2,361 women with infertility from the National Survey of Fertility Barriers. Latent class analysis uncovered seven latent classes of behavioral response which can be arranged in a rough continuum from least medicalized to most medicalized response. We then aggregated these seven categories into three schemas representing various degrees of medicalization. Women in each class combine treatment-seeking, knowledge-seeking, socio-emotional support seeking, and non-medical solution-seeking strategies. Even women pursuing the greatest degree of medicalization in their health-seeking (e.g., fertility treatments, assisted reproduction) made use of a variety of medical and non-medical health-seeking resources.

Is infertility resolution associated with a change in women's well-being?

STUDY QUESTION: Is giving birth associated with improved subjective well-being among involuntarily childless women? SUMMARY ANSWER: Resolution of infertility is associated with increased life satisfaction and self-esteem, but not with a decrease in depressive symptoms. WHAT IS KNOWN ALREADY: Cross-sectional data and studies of treatment-seekers show that infertility is associated with lower subjective well-being. Childless women with infertility tend to report lower subjective well-being than women who experience secondary infertility, but a prospective study using a random sample of involuntarily childless women over time has not previously been conducted. STUDY DESIGN, SIZE, DURATION: The sample for the current study includes all women without children who met medical criteria for infertility or perceived a fertility problem (N = 283) at baseline and who were interviewed in both waves (3 years apart) of the National Survey of Fertility Barriers (NSFB), in a random-digit dialing telephone survey. It is therefore possible to explore here whether there are differences in the association of infertility resolution and subjective well-being among women who do and do not perceive themselves as having a fertility problem. PARTICIPANTS/MATERIALS, SETTING, METHODS: Depressive symptoms (as measured by the Center for Epidemiologic Studies-Depression Scale), self-esteem (as measured by a modified version of the Rosenberg Self-esteem Scale) and life satisfaction (as measured by a modified version of the Satisfaction with Life Scale) were assessed for all 283 participants at both waves. For all three variables, change scores of 47 involuntarily childless women who resolved their infertility through a live birth were compared to the scores for the 236 women who remained childless. A number of variables shown to be associated with subjective well-being among infertile women were included as controls. MAIN RESULTS AND THE ROLE OF CHANCE: No relationship between infertility resolution and change in depressive symptoms was observed (b = -0.04; P > 0.05). Involuntarily childless women who resolved their infertility improved in self-esteem (b = 0.74; P < 0.01) and life satisfaction (b = 1.06; P < 0.01). LIMITATIONS, REASONS FOR CAUTION: Women were measured at only two time points. Only 47 women had a live birth between waves. While it is common practice to make causal interpretations based on panel data, such interpretations should be made with caution. In addition, the NSFB was conducted in the USA where medical expenditures are high and most fertility treatment expenses are not covered by insurance. Thus it may not be possible to generalize the findings to other modern industrialized societies. WIDER IMPLICATIONS OF THE FINDINGS: Knowing that resolution of infertility is associated with improved subjective well-being is important for infertile couples and infertility professionals alike. STUDY FUNDING/COMPETING INTEREST(S): This research was supported in part by NICHD grant R01-HD044144 and NIGMS grant P20-GM109097 from the National Institutes of Health. The authors have no competing interests.

Is perception of inability to procreate a temporal phenomenon?: A longitudinal exploration of changes and determinants among women and men of reproductive age in Germany.

Continued postponement of births and increasing use of reproductive medicine enhance the relevance of infertility and related perceptions for fertility research. Fertility researchers tend to assume that an existing perception of inability to procreate is a stable trait among persons of reproductive age. This assumption is questionable from a life course perspective and has not been thoroughly investigated. Therefore we investigate the prevalence, stability, and correlates of perceived inability to procreate. We apply between-within logit models to annual panel data (2008-2015) to study variation in perceived inability to procreate within individuals over time and between individuals. We find that approximately every 20th person of reproductive age is affected. There is considerable instability among those who ever perceive an inability to procreate: On average, 39 % of women and 48 % of men who perceive an inability in one year change to not perceiving an inability in the next year. Multivariate analysis shows that increases in age and perception of one's partner as unable to procreate are associated with higher odds of perceiving an inability to procreate. Not using contraception is associated with higher odds of perceiving an inability to procreate. Perceived procreative ability further differs by parity, level of education, immigration background, and religious denomination. In summary, perception of inability to procreate is a temporal phenomenon that is shaped by lifecourse contexts and social group differences.

Exploring Experiences with Sterilization among Nulliparous Women.

Although nulliparous women who are sterilized appear voluntarily "childfree," the majority report non-contraceptive reasons for their surgical procedure. Using an analytical subsample of the National Survey of Fertility Barriers, we examined 105 women's closed- and open-ended responses about the reasons for their sterilization surgeries and whether their sterilization occurred before their childbearing desires were met. We found considerable heterogeneity in the experiences and attitudes of participants. We highlight important implications of women's experiences for fertility and reproductive health research and practice, particularly by drawing a distinction between voluntarily childfree and involuntarily childless women.

Concerns about treatment for infertility in a probability-based sample of US women.

Objective: Many women experience infertility as distressing, but only about half of US women seek medical services. It is unknown whether concerns about fertility treatment are related to receiving fertility treatment or to distress levels.Methods: Using the nationally representative National Survey of Fertility Barriers, we constructed a nine-item scale measuring fertility treatment concerns. The analytical sample for this study included 1218 women who said that they were trying to become pregnant and who were asked questions regarding treatment concerns. We conducted multiple regression analysis to discover factors associated with treatment concerns and whether treatment concerns were associated with depressive symptoms and fertility-specific distress. We used logistic regression to determine whether treatment concerns were associated with receiving fertility tests.Results: Desiring a(nother) child, infertility stigma, higher family income, higher economic hardship and claiming a Hispanic identity were associated with higher levels of treatment concerns than those in the comparison groups. Having friends and family with children and having private health insurance were associated with lower levels of concern. Treatment concerns were not associated with receiving fertility tests. Higher levels of treatment concern were associated with higher levels of fertility-specific distress and depressive symptoms. Higher infertility stigma was related both directly and indirectly to higher levels of fertility-specific distress and depressive symptoms.Conclusion: For US women, fertility treatment concerns are not associated with whether women pursue fertility testing, but they are associated with higher levels of fertility-specific and general distress.

Change in Motherhood Status and Fertility Problem Identification: Implications for Changes in Life Satisfaction.

OBJECTIVE: To determine whether the association between changes in life satisfaction and becoming a mother (or not) depends on fertility problem identification status. BACKGROUND: Evidence and symbolic interactionist theory suggest that, for women who initially perceive a fertility barrier, gaining the valued identity "mother" should be associated with increases, and continuing to face a blocked goal (i.e. not becoming a mother) should be associated with decreases in life satisfaction. METHOD: This study used the nationally representative two-wave National Survey of Fertility Barriers to conduct a change-score analysis with chained multiple imputation (MICE). The focal dependent variable was change in life satisfaction. Focal independent variables were Wave 1 life satisfaction, fertility problem identification status, and birth between waves, controlling for stability and change in relationship status, talking to a doctor about how to get pregnant, religiosity, social support, importance of parenthood, importance of leisure, importance of work success, and economic hardship. RESULTS: Among women who perceived a fertility problem at both waves, becoming a mother was associated with increased life satisfaction and not becoming a mother was associated with decreased life satisfaction. Women who gained or lost a fertility problem perception between waves but did not have a live birth experienced a gain in life satisfaction between waves, suggesting the relevance of the duration of fertility problem perception for change in life satisfaction.

'Just because a doctor says something, doesn't mean that [it] will happen': self-perception as having a Fertility Problem among Infertility Patients.

Only some individuals who have the medically defined condition 'infertility' adopt a self-definition as having a fertility problem, which has implications for social and behavioural responses, yet there is no clear consensus on why some people and not others adopt a medical label. We use interview data from 28 women and men who sought medical infertility treatment to understand variations in self-identification. Results highlight the importance of identity disruption for understanding the dialectical relationship between medical contact and self-identification, as well as how diagnosis acts both as a category and a process. Simultaneously integrating new medical knowledge from testing and treatment with previous fertility self-perceptions created difficulty for settling on an infertility self-perception. Four response categories emerged for adopting a self-perception of having a fertility problem: (i) the non-adopters - never adopting the self-perception pre- or post-medical contact; (ii) uncertain - not being fully committed to the self-perception pre- or post-medical contact; (iii) assuming the label - not having prior fertility concerns but adopting the self-perception post-medical contact; and (iv) solidifying a tentative identity - not being fully committed to a self-perception pre-medical contact, but fully committed post-medical contact. (A virtual abstract of this paper can be viewed at: https://www.youtube.com/channel/UC_979cmCmR9rLrKuD7z0ycA).

Decline in ethical concerns about reproductive technologies among a representative sample of US women.

Public awareness and utilization of assisted reproductive technology has been increasing, but little is known about changes in ethical concerns over time. The National Survey of Fertility Barriers, a national, probability-based sample of US women, asked 2031 women the same set of questions about ethical concerns regarding six reproductive technologies on two separate occasions approximately 3 years apart. At Wave 1 (2004-2007), women had more concerns about treatments entailing the involvement of a third party than about treatments that did not. Ethical concerns declined between Wave 1 and Wave 2, but they declined faster for treatments entailing the involvement of a third party. Ethical concerns declined faster for women with greater levels of concern at Wave 1. Initial ethical concerns were higher, and there was less of a decline in ethical concerns for women with higher initial levels of religiosity.

Responding to Infertility: Lessons From a Growing Body of Research and Suggested Guidelines for Practice.

Infertility is a common, yet often misunderstood, experience. Infertility is an important topic for family scientists because of its effects on families; its relevance to research in related areas, such as fertility trends and reproductive health; and its implications for practitioners who work with individuals and couples experiencing infertility. In this review, we focus on common misperceptions in knowledge and treatment of infertility and highlight insights from recent research that includes men, couples, and people with infertility who are not in treatment. The meaning of parenthood, childlessness, awareness of a fertility problem, and access to resources are particularly relevant for treatment seeking and psychosocial outcomes. On the basis of insights from family science research, we provide specific guidelines for infertility practice within broader social contexts such as trends in health care, education, employment, and relationships. Guidelines are presented across three areas of application: infertility education for individuals, families, and practitioners; steps to support the emotional well-being of those affected by infertility; and understanding of treatment approaches and their implications for individuals and couples.