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PCHHC Newsletter
October 2015
Infertility & Preconception Health  
One in eight US couples of childbearing age have trouble conceiving or maintaining a pregnancy.  Infertility, a disease of the reproductive system, affects people from all walks of life, cutting across racial and ethnic lines, class distinctions, and age.  Approximately 30% of infertility can be attributed to male factors, 30% to female factors, 10% due to a combination of problems in both partners, and the remaining proportion is unexplained.  Medications, such as those used for cancer treatment, environmental and occupational exposures, infections, structural abnormalities of the reproductive system, and conditions such as endometriosis and polycystic ovarian syndrome can all cause infertility. 

When discussing reproductive life planning, clinicians and public health leaders often focus on making sure people of reproductive age have access to effective contraception.  While ensuring that the full suite of contraceptive methods is available to all is critical, we cannot forget the importance of access to infertility prevention, diagnosis, and treatment as a key component of comprehensive preconception health initiatives and care. The new Quality Family Planning Guidelines take an important step forward by covering some basic services through Title X. We need to follow and build on their lead. There are disparities by race, ethnicity, and income in terms of who is able to access infertility services that must be addressed as part of a reproductive equity agenda. We also cannot assume that couples undergoing fertility treatment are receiving comprehensive preconception health counseling.

Infertility Surveillance, Prevention, Detection, and Treatment
There is limited information available at a national level about the burden of infertility in the United States.  The National Survey of Family Growth - 2011-2013 reports that 12.3% of all women age 15-44 report impaired fecundity - that is, they are not surgically sterile, yet find it difficult or impossible to get pregnant or carry a pregnancy to term.  Among married, childless women of reproductive age, the proportion reporting impaired fecundity is almost a quarter (24.2%).  In the NSFG, infertility - the inability to conceive - is only reported for married women.  The NSFG reports that 6.1% of all reproductive-age married women are infertile, a proportion that increases to 13.5% among childless married women of reproductive age.

The CDC Divison of Reproductive Health, in consultation with other governmental and non-governmental organizations, has released the National Public Health Action Plan for the Dete ction, Prevention, and Management of Infertility.  The plan details the need to better understand the population-level issues that contribute to and cause infertility and may affect the health of a pregnancy. Specifically, it focuses on promoting healthy behaviors that can maintain fertility, encouraging prevention, early detection, and swift treatment of conditions that can threaten fertility, and reducing exposure to infectious, iatrogenic, environmental, and occupational exposures that can harm fertility.  CDC has also released a grand rounds video titled Time for Public Health Action on Infertility.

Sexually transmitted infections (STIs) such as chlamydia and gonorrhea, can cause pelvic inflammatory disease (PID), which in turn can lead to infertility.  As reported by the National Chlamydia C oalition, chlamydia is common in adolescents and young adults in the US, with an estimated 2.8 million new cases per year. One out of every 15 sexually active adolescent girls in the US has chlamydia.  Twenty percent of untreated chlamydia infections result in PID, making this STI the leading cause of tubal factor infertility in the US.  CDC's 2015 STD Treatment Guidelines indicate yearly screening of all sexually active females <25 years and older women at increased risk for infection for chlamydia and gonorrhea - a screening that the National Commission on Prevention Priorities ranks as a high value, but underused clinical preventive service. Routine chlamydia screening could reduce the incidence of PID by up to 60%. 

See the 2015 STD Treatment Guidelines site for a provider-focused pocket card and wall chart, as well as an app that combines information from the STD Treatment Guidelines as well as MMWR updates.  For more information about chlamydia, including provider guidelines and resources, see the National Chlamydia C oalition.  Of particular interest may be their Sexual Health Resource Exchange, where you can search and download customizable public awareness and education materials and share your resources.

Despite the fact that infertility is classified as a disease, only 15 states currently require any insurance coverage of infertility diagnosis or treatment, and only 8 of those mandate coverage of assisted reproductive technology (ART), such as in-vitro fertilization (IVF).  Resolve: The National Infertility Association, which seeks to increase public awareness of infertility, provides patient and provider information, facilitates support groups, and advocates for access to all family-building options, released their 3rd annual State Fertility Scorecard in August. 
The Fertil ity Scorecard evaluates states based on the number of peer-led RESOLVE infertility support groups; the number of fertility doctors at accredited clinics; the number of women in the state who experienced impaired fecundity; and state insurance mandates (or lack thereof).  Additionally, blue dots were placed on states with pending legislation that could affect access to infertility diagnosis and treatment.

Assisted reproductive technology (ART), including treatments such as in-vitro fertilization (IVF), can provide people with infertility the chance to conceive, but also presents significant public health challenges due to the substantial risk for multiple birth delivery, which is associated with poor maternal and infant health outcomes. Even when elective single embryo transfer is appropriate, many couples choose to transfer multiple embryos per cycle.  This is influenced by access to and affordability of treatment, as well as the desire to minimize the number of ART cycles experienced by the woman. Since most ART are not covered by insurance, couples have to pay the relatively high cost of the procedures out of pocket.  For example, the median cost of a single IVF cycle in the US, including medications, is $19,200.  As a result, many people are not able to afford treatment, while others are choosing to transfer multiple embryos per IVF cycle to increase the chances of success. 

  The   Fertility Clinic Success Rate and Certification Act mandate s that all ART cycles performed in US fertility clinics are reported to CDC, which collects data on patient demographics, procedures, and outcomes per cycle in the National ART Surveillance System (NASS).  The latest surveillance summary from the NASS, published in MMWR - Assisted Reproductive Technology, 2012 - details access to infertility treatment, pregnancy outcomes per cycle, and perinatal outcomes for the infants resulting from ART.  Building on these national surveillance efforts, CDC, in coordination with the Departments of Health in Connecticut, Florida, Massachusetts, and Michigan, has also established the States Monitoring Assisted Reproductive Technology (SMART) Collaborative.  The goal of the SMART Collaborative is to strengthen the capacity of states to monitor ART-related maternal and perinatal outcomes using state-level data. The Association of State and Territorial Health Officials (ASTHO) has a fact sheet providing additional information about the SMART Collaborative and the initiatives in the four participating states.
Recent Articles
Relevant articles from the public health community on health disparities and infertility.
Disparities in Access to Effective Treatment for Infertility in the United States
An American Society for Reproductive Medicine Ethics Committee opinon, the article details the unmet need in treating infertility, economic barriers to treatment, and other disparities, including paid time off to attend appointments and geographic distribution of reproductive endocrinologists and urologists.  The article notes that some biological causes of infertility may vary by race, ethnicity, or sex, yet are rarely researched along demographic lines.  The authors also state that some groups, including minority women, tend to seek medical advice after experiencing a longer duration of infertility, contributing to lower pregnancy success rates, and that physician referral patterns for fertility preservation have been shown to vary according to patient race/ethnicity, sexual orientation, and socioeconomic status - patterns that may also apply to other fertility treatments.  The article also details disparities in the outcomes of infertility treatment, stating that research on IVF outcomes by race/ethnicity show lower implantation and clinical pregnancy rates and increased miscarriage rates among African American, Asian, and Hispanic women as compared to non-Hispanic white women.  The authors write that the further study and rectification of these differences in treatment outcomes are critical to achieving health equity among women and men across all racial and ethnic groups. The article concludes by considering the ethical benefits of improving infertility treatment access and outcomes, as well as suggesting strategies for increasing access to ART among all populations, including those with limited English proficiency and those living in rural or under-served areas, and strategies for reducing the cost-burden of treatment on patients.  

Racial and ethnic disparities in reproductive endocrinology and infertility
This review examines racial and ethnic disparities in reproductive health focusing on infertility, polycystic ovarian syndrome, and reproductive aging. The authors report that an increasing body of knowledge points toward reduced infertility treatment access and IVF outcomes in African American, Asian, and Hispanic women compared with white women, as well as differences in the reproductive and metabolic phenotypes of Asian, black, and Hispanic women presenting with polycystic ovarian syndrome when compared with white women.  The authors note that reproductive aging differences exist in all racial and ethnic groups.  

Cultural factors contributing to health care disparities among patients with infertility in Midwestern United States
The authors surveyed 1,350 women (median age 35) seen in a university-based reproductive endocrinology clinic, of whom 41% were white, 28% African American, 18% Hispanic, and 7% Asian.  The authors found that, compared with white women, African American and Hispanic women had been attempting to conceive for 1.5 years longer and found it more difficult to get an appointment, to take time off from work, and to pay for treatment. Forty-nine percent of respondents were concerned about the stigma of infertility, 46% about conceiving multiples, and 40% about financial costs. Disappointing one's spouse was of greater concern to African-American women, whereas avoiding the stigmatization of infertility was of greatest concern to Asian-American women.

The Maternal and Child Health Journal is soliciting manuscript submissions for an upcoming themed issue focusing on postpartum health and wellness. Papers on any aspect of postpartum health are welcome, including policy briefs, original research, program implementation, commentaries, perspectives in practices, evaluation, and lit reviews. New deadline is Dec 1st, 2015. Email Sarah Verbiest with questions.  
Click here for more information about manuscript submissions.
Congratulations to  Healthy Women Healthy Futures, the Tulsa Family Health Coalition and Su Ann Phipps for winning a Community Champion Award for Behavioral Health at the Oklahoma Turning Point Conference in September!  OK Turning Point transforms public health in Oklahoma by working directly with community partners to identify local priorities and solutions to improve health. Annually, they reward an initiative, project, or event in the Turning Point Partnership that has contributed to the overall health and/or quality of life in the community it serves.  Healthy Women, Healthy Futures is a member of the Tulsa Family Health Coalition, and supports inter-conception  health, pregnancy, and healthy birth outcomes through education, care coordination, home visitation, and access to health care.  Congratulations on this recognition of the impact you are making in women's lives in Oklahoma!

CDC's Morbidity and Mortality Weekly Report has published a new study looking at alcohol use among pregnant and nonpregnant women of childbearing age in the United States. According to the report: Among non-pregnant women aged 18-44, 1 in 2 (53.6%) reported any alcohol use, and 1 in 5 (18.2%) reported binge drinking in the past 30 days. Among pregnant women, 1 in 10 (10.2%) reported any alcohol use and 1 in 33 (3.1%) reported binge drinking in the past 30 days. About one third of pregnant women who drink alcohol engage in binge drinking.

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