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Medical and social inequalities behind racial disparities in fertility outcomes

31 August 2021
By Dr Alka Prakash and Mrs Uma Gordon
Dr Alka Prakash, consultant clinical lead, Cambridge IVF, Cambridge University Hospitals NHS trust and Mrs Uma Gordon, consultant gynaecologist and subspecialist in reproductive medicine and surgery, clinical director, Bristol Fertility Clinic.
Appeared in BioNews 1110

A recent Human Fertilisation and Embryology Authority (HFEA) report has indicated that people from black, Asian and ethnic minority backgrounds undergoing fertility treatment are less likely to have a baby, with black patients having the lowest chances of successful treatment (see BioNews 1089). This is indeed concerning and needs urgent action to address the inequality. 

Various reasons have been cited for the differences. Among the medical factors, black women are known to have an increased incidence of uterine fibroids and tubal factors that impact fertility negatively, as shown by results of a survey published in the Journal of Women's Health in 2013. Women who have had multiple surgeries to treat gynaecological symptoms prior to presentation with subfertility can have adversely impacted fertility outcomes, even though the surgeries helped with symptoms. Similarly, Asian populations are known to have a higher incidence of polycystic ovarian syndrome that impairs ovulation thereby leading to subfertility. 

Medical reasons in isolation, however, do not explain the poorer outcomes of fertility treatment among ethnic minority populations. As we look at the data provided by the HFEA, it is clear that fertility treatment is accessed at a later age by this subgroup of women. Female age, as we know, is the single most important prognostic factor for live birth outcome. Hence medical comorbidities along with delayed access to fertility treatment can to some extent explain the findings of this report.

Black women also appear to have more complications such as multiple pregnancies associated with fertility treatments. This might be due to increased age at treatment leading to poorer quality embryos, and a tendency towards double embryo transfers to optimise success rates. 

Addressing these inequalities will require a focus on medical issues as well as social inequalities. These common conditions have medical treatments which are effective when offered as fertility preserving procedures such as myomectomy for fibroid uterus. Women should be informed about the adverse impact of delayed child bearing with such pathologies. Similarly in metabolic conditions like polycystic ovarian syndrome, early advice on weight loss and lifestyle measures allow for spontaneous conception and increased success with treatment options. 

Concerning the social aspects, infertility as a disease has been stigmatised almost universally. This social stigma appears to be more pronounced in these ethnic subgroups creating a resistance to access help at the right time, as shown in a 2015 paper published in Psychology of Women.

Increasing awareness through knowledge is key to addressing these issues. Opportunistic discussion about future fertility at primary care level would be a good start to give this subgroup relevant and timely information. In addition, it is important to involve the community through religious and social leaders. They will have a greater understanding of the cultural and religious beliefs, to help influence and overcome barriers. It will also help destigmatise the process of fertility treatment, so that more people from ethnic minorities come forward for gamete donation.

It is evident from the HFEA report that there is a serious lack of availability of donated eggs in the UK from black, Asian and ethnic minority subpopulation, necessitating the use of eggs from white donors by those patients who require donor gametes.

There are other social issues that can impact fertility outcome. Socially deprived areas often have poor diet/living conditions, increased environmental pollution and stress, leading to overall poorer health outcomes. Furthermore, the access to state funded fertility treatment varies regionally and some of the ethnic minorities may have been much more impacted by this. This postcode inequality needs to be redressed to enable equity in health services provision.

The HFEA report is very much welcomed and helps highlight some very important facts. It would, however, be good to scrutinise specifics within each of the different ethnic groups, as the needs and requirements vary widely. There is an urgent need for further research in this area to distil the various causes and take action to challenge the problem.

Information provision across the fertility sector needs to be improved and we should put in place early access criteria for these women for both fertility assessment and treatment. Broader issues such as systemic racism need to be identified and tackled as they may also deter women from accessing care and treatment. We, as multidisciplinary members and practitioners of the sector, need to take individual onus and responsibility to do all it takes to eradicate this inequality. We look upon the national professional bodies such as the British Fertility Society, The Royal College of Obstetricians and Gynaecologists' Race Equality Taskforce and the HFEA to guide this fight against health disparity based on ethnicity.  

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